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PRACTICAL  CLOICAL  LESSONS 


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SYPHILIS 

A2sB    THE  . 

GENITO-URI>TARY     DISEASES 

VOL.  I 
SYPHILIS    Al^D    OHAlsrOEOID 

BY 

FESSENDEN^  N.   OTIS,  M.D. 

CLINICAL  PROFESSOR    OP    GEXITO-URINARY  DISEASES     IN    THE    COLLEGE  OF  PHYSICIANS 

AND     SURGEONS,    NEW    YORK;     SURGEON    To     CHARITY     HOSPITAL;    COXSULTINO 

SURGEON  TO  ST.   ELIZABETH'S  HOSPITAL,    TO    THE   NEW  YORK  SKIN  AND 

CANCER    HOSPITAL,   AND     TO     THE     COLORED     ORPHAN     ASYLUM  ; 

FELLOW    OF    THE    NEW    YORK    ACADEMY     OF    MEDICINE  ; 

MEMBER  OF  THE  BRITISH  MEDICAL  ASSOCIATION, 

ETC. 


NEW  YORK 

BEEMINGIIAM  &   CO 

1883 


Copyright,  1883,  by  Bermingham  &  Co. 


TO 
WILLARD    PAEKER,   M.D.,    LL.D. 

EMERITUS     PROFESSOR     OF     SURGERY     IN     THE     COLLEGE     OF 

PHYSICIANS    AND     SURGEONS, 

NEW    YORK. 

RENOWNED   AS  A   TEACHER,    DISTINGUISHED   AS   A   SURGEON, 

EMINENT  AS   A   CITIZEN,  UNIVERSALLY   BELOYED 

FOR  HIS   NOBLE   NATURE  AND   HIS 

GENEROUS     ACTS, 


@;i)is  toork, 


WITH    HIS    CONSENT,  IS    GRATEFULLY    AND    AFFECTIONATELY 

DEDICATED    BY    ONE,  AMONG    THE    MANY,  OF    HIS 

MEDICAL   BRETHREN,   WHO    OWE   TO   HIM — 

NOW  FULL  OF  YEARS  AND   HONOES 

— THE  GREATEST  MEASURE 

OF   THEIR 

PROFESSIONAL    SUCCESS. 


PREFACE. 


For  a  number  of  years  it  has  been  my  Custom,  to  dis- 
tribute, from  time  to  time,  to  the  students  of  the  Col- 
lege of  Physicians  and  Surgeons,  short  papers,  of  a  few 
pages  each,  which  were  entitled  "  Class-room  Lessons." 
In  these  I  endeavored  to  embody  important  principles, 
in  the  study  of  syphilis  and  the  genito-urinary  diseases. 
The  lessons  were  intended  to  prevent  errors,  arising 
from  inattention,  or  from  misunderstanding  of  the  state- 
ments made  during  the  lectures  in  the  college,  and  at 
Charity  Hospital.  This  was  rendered  especially  neces- 
sary, from  the  fact  that  my  own  views,  on  certain  im- 
portant points,  differed,  essentially,  from  those  embodied 
in  the  text-books  in  general  use.  In  the  first  place,  on 
the  subject  of  syphilis :  I  had  been  unable  to  accept  the 
statements  of  all  authorities,  that  it  was  a  mysterious, 
instantaneous,  poisoning  of  the  organism,  in  defiance  of 
all  known  physiological  and  pathological  laws.  A  care- 
ful study  of  the  matter,  in  connection  with  modern  dis- 
coveries in  physiology  and  pathology,  had  convinced 
me,  that  an  explanation  of  all  the  lesions  and  m.anifesta- 
tions  of  syphilis  was  possible,  through  known  phj'siologi- 
cal  and  pathological  processes,  and  that,  the  then  uni- 
versally accepted  view  of  the  supernatural  advent  and 
behavior  of  syphilis,  was  incorrect.  This  position  was 
taken,  in  my  lectures  in  the  college,  in  1868.  In  1870,  it 
was  presented  to  the  medical  profession,  in  a  paper  be- 
fore the  Medical  Society  of  the  county  of  New  York, 
and  was  followed  by  another  paper,  on  the  same  subject, 
in  1871.  Up  to  that  time,  no  systematic  effort  had  been 
made  to  explain  the  various  manifestations  of  syphilis, 
on  a  scientific  basis.  In  1866,  Beale  had  claimed,  from 
his  investigations  of  variola  and  the  cattle  disease,  the 


6  PREFACE. 

presence  of  a  germinal  cell,  as  a  cause  of  syphilis.  Bei- 
siadecki,  of  Krakow,  had  published,  in  1867,  the  results 
of  his  microscopical  examination  of  infecting  chancre, 
in  which  he  showed  a  localized  proliferation  of  cell  ele- 
ments in  the  lymphatic  vessels,  as  a  starting-point  in 
syphilis,  and  claimed  that  this  migJit  afford  an  explana- 
tion, through  which  the  general  infection  might  be  ex- 
plained. I  took  up  the  matter  at  this  point,  and  through 
the  results  of  pathological  and  histological  researchcc  of 
accepted  authorities  in  pathology  and  histology,  in  other 
fields,  succeeded,  as  I  believed,  in  explaining  the  various' 
syphihtic  phenomena  throughout  the  entire  course  of 
the  disease.  A  review  of  my  papers,  in  the  London 
Lancet  of  Nov.  9th,  1872,  concluded  with  the  statement 
that  ''  these  new  views  on  the  physiology  of  syphilitic 
infection  are  not  based  upon  the  results  of  any  experi- 
ments or  new  facts,  or  on  the  unravelling  of  observa- 
tions. They  consist  mainly  of  deductions  drawn  from 
a  close  and  elaborate  reasoning  on  the  acknowledged 
features  of  syphilis  in  connection  with  the  latest  doc- 
trines and  hypotheses  of  certain  pathological  teachers." 
Starting  with  the  disease-germ,  derived  from  the  de- 
graded human  germinal  cell  of  Beale,  supported  by  the 
microscopic  examinations  of  Beisiadecki  and  Verson, 
as  to  the  proliferation  of  new  cell  material  at  the  site  of 
syphilitic  inoculation,  and  extending  only  in  the  hue 
lymph  channels  ;  supported  still  farther  by  the  clinical 
facts,  in  regard  to  gradual  implication  of  lymph  vessels 
and  glands,  by  the  known  physiological  processes  in 
health,  and  under  the  influence  of  syphilitic  infection, 
and  also  through  the  concurring  testimony  of  such  his- 
tological and  pathological  authorities  as  Chaveau, 
Beale,  Schweiggerseidel,  Strieker,  KoUiker,  Teichman, 
Kohn,  Conhiem,  Beisiadecki,  and  others,  I  was  enabled 
to  present  a  reasonable  explanation  of  the  course  of 
syphihs,  from  its  inception  to  its  termination.  It  was 
scarcely  to  be  expected,  that  such  a  radical  departure 
from  the  views  of  the  text-books,  would  be  received 
without  discussion;  but  the  position  taken  was  so 
amply  supported  by  all  known  pysiological  and  patho- 
logical facts,  that  no  opposing  arguments  were  oifered. 


PREFACE.  7 

The  first  authoritative  publication  in  America  which 
followed,  practically  adopted  and  supported  the  new 
views  thus:  (Bumstead  and  Taylor,  N.  Y.,  1869,  4th 
ed.  page  443)  ''  The  secretions  of  syphilitic  lesions 
are  found  to  consist  of  a  serous  fluid  containing  numer- 
ous granules  or  molecules,  which  are  masses  of  proto- 
plasm or  germinal  matter  holding  the  contagious  properties 
of  syphilis.  These  microscopic  bodies  are  probably 
taken  into  the  circulation  by  the  lymphatics,  and  con- 
veyed over  the  body.  .  .  In  the  secondary  period  of 
syphilis  these  cells  are  very  numerous,  and  the  body 
may  be  covered  with  papules  and  tubercles  composed  of 
them.  .  .  As  the  disease  wanes  .  .  the  cells  no  longer 
have  a  tendency  to  reproduction  which  characterizes 
them  in  the  early  stages,  but  rather  degenerate.  Hence 
we  consider  the  blood  and  the  secretions  in  tertiary  syphilis 
innocuous!'  * 

The  same  views  of  syphilitic  infection  were  presented 
in  the  second  edition  of  Berkeley  Hill's  work,  by  Berk- 
eley Hill  and  Arthur  Cooper,  London,  1881  (p.  75), 
and  erroneously  attributed  to  Auspitz  of  Vienna  (al- 
though in  a  foot-note  the  reader  is  referred,  for  further 
information  on  the  subject,  to  my  work  on  the  Physio- 
logical Pathology  and  Treatment  of  Syphilis)  thus : 
"  The  syphihtic  virus  enters  the  system  by  the  absorb- 
ents. It  first  sets  up  plastic  growth  in  the  walls  of  the 
lymphatic  vessels  at  the  part  where  it  is  implanted. 
These  walls  thicken  and  throw  off  into  their  interior, 
cells  which  contain  the  virus ;  as  these  cells  float  along 
they  convey  the  virus  still  further  inwards.  But  the 
infiltration  of  successive  parts  of  the  walls  of  the  lym- 
phatic vessels  also  conducts  the  virus  inwards.  When 
a  lymphatic  gland  is  reached,  the  same  proliferating  pro- 
cess ensues  in  the  gland,  until  the  cells  are  sent  off 
through  the  effersent  ducts  to  other  glands,  and  so  on  to 
the  thoracic  duct.  Thence  cells,  containing  the  virus, 
are  poured,  direct  into  the  circulation,  by  the  veins,  and 
are  thus  quickly  carried  to  the  several  tissues  of  the  body. 
Then  appear  the  signs  of  general  constitutional  infection.'' 

*  Italics  my  own. 


S  PREFACE. 

Again,  in  the  work  of  M.  Cornil  on  syphilis  (Paris,  1878), 
translated  and  edited  by  Profs.  Simes  and  White,  of  the 
University  of  Penns34vania,  '*  with  the  consent  and  ap- 
proval of  the  author,"  and  pubhshed  in  1882,  this  same 
view  of  the  mode  of  syphihtic  infection,  is  extracted  from 
my  book,  preceded  by  a  statement  (p.  21)  of  opinion  that, 
"  it  presents  fewer  inconsistencies  than  any  of  the  other  the- 
ories/'  and  on  page  23,  "  that  it  seems  impossible,  in  the 
light  of  certain  well-known  facts,  to  deny  that  the  syph- 
ilitic poison  gains  access  to  the  general  circulation,  chief- 
ly, if  not  entirely,  by  the  lymphatics ;"  and  again,  page 
25,  "the  action  of  mercury  in  relieving  the  early  symp- 
toms, also  becomes  intelligible  in  the  light  of  this  the- 
ory, through  its  influence  in  hastening  destructive  met- 
amorphosis and  bringing  about  fatty  degeneration ; 
and  its  general  undoubted  tendency  to  relieve  tissues 
encumbered  with  superfluous  material.  Small  doses, 
most  naturally,  first  influence  newly-formed  immature 
deposits,  such  as  those  due  to  syphilis,  and  hence  the 
advantage  of  the  modern  treatment,  which  avoids  sali- 
vation, due  to  the  toxic  action  of  the  drug  on  the  healthy 
tissues,  and  depends  upon  moderate,  long-continued 
doses.  The  necessity  for  the  use  of  iodide  of  potassium,  in 
the  later  stages,  with  or  without  mercury,  also  becomes 
apparent,  when  it  is  remembered  that  iodine  is  the  most 
powerful  diffusible  stimulant  of  the  function  of  absorp. 
tion.  with  which  we  are  acquainted,  and  that  also,  it  has 
a  certain  established  value,  in  hastening  tissue  change, 
especially  in  unhealthy  formations." 

In  view  of  the  direct,  or  implied,  approval  of  my  posi- 
tion, by  these  recent  eminent  authorities  in  matters  in- 
volving the  nature,  behavior,  and  treatment  of  syphilis, 
it  has  seemed  proper  that  I  should  make  use  of  every 
opportunity  to  advance  these  views,  and  to  explain,  on 
physiological  and  histological  grounds,  the  various 
pomts  in  the  diagnosis  and  treatment  of  cases  of  spyhi- 
lis  and  its  sequelas,  herewith  presented. 

In  the  second  place :  Early  in  my  clinical  teaching,  I 
had  found  myself  unable  to  accept  the  conventional 
views,  held  by  authorities  on  many  important  points  in 
genito-urinary  diseases.     Especially  as  to  the    nature 


PREFACE.  9 

and  treatment  of  gonorrhoea  and  urethral  stricture  and 
the  normal  urethral  calibre.  As  to  the  latter,  I  could 
not  accept  the  standard  universally  taught,  but  claimed, 
from  actual  measurements,  an  individuality  for  every 
urethra,  a  proportionate  relation,  between  the  size  of 
the  urethra  and  the  organ  in  which  it  is  situated,  and 
an  average  calibre,  much  greater  than  previously  esti- 
mated. I  also  claimed,  contrary  to  all  previous  teach- 
ing, a  radical  cure  of  urethral  stricture,  through  com- 
plete division.  These  views,  and  others  growing  out  of 
them,  involving  important  questions  in  practice,  sup- 
ported by  several  hundreds  of  practical  examples,  de- 
fended in  written  and  in  oral  debate,  against  eminent 
authorities  in  this  country  and  in  Europe,  made  it  es- 
pecially necessary  for  me  to  have  a  medium  of  com- 
munication with  students,  which  could  not  be  misin- 
terpreted or  misunderstood.  With  an  especial  view  to 
this,  the  second  volume  of  this  work  was  suggested. 
No  attempt  has  been  made  to  make  it  a  systematic 
general  exposition  of  genito  -  urinary  diseases.  The 
aim  has  been,  chiefly,  to  present  clinical  cases,  selected 
as  typical  and  practical,  which  have  been  subjects  of  ob- 
servation and  study,  in  my  private  practice,  and  in  my 
cliniques,  and  such  additional  material  illustrative  of 
important  practical  points,  and  m}^  own  experience  in 
the  treatment  of  such  cases,  as  I  could  readily  com- 
mand. When  some  learned  and  not  too  busy  surgeon, 
in  gathering,  from  every  quarter,  the  material  for  a  full 
and  systematic  treatise  on  genito-urinary  troubles, 
meets  the  everyday  experiences  which  have  been  pre- 
sented in  the  foregoing  pages,  it  is  my  ambition,  that 
some  points  may  be  found  among  them,  which  will  be 
considered  worthy  of  preservation,  in  more  pretentious 
form.  Meanwhile,  I  trust  that  many  surgeons  may  find, 
in  th.e  cases  recited,  and  in  the  principles  and  treatment 
advocated,  a  key  which  will  help  to  explain  much  that 
has  heretofore  appeared  obscure,  and  difficult  of  man- 
agement. 

F.  N.  Otis. 

New  York,  108  West  34th  Street,  April  30,  1883. 


CONTENTS. 


LESSON    I. 

PACK 

Nature  of  Gonorrhoea,  Chancroid,  and  Syphilis — The  Initial  Lesion 
of  Syphilis 17 


LESSON   IL 
The  Initial  Lesion  of  Syphilis — {Continued^ 27 

LESSON  in. 
The  Initial  Lesion  of  Syphilis — {Continued) 32 

LESSON  IV. 
Syphilis  by  Hereditary  Transmission 42 

LESSON  V. 
Early  Differential  Diagnosis 50 

LESSON  VI. 
Progress  of  the  Syphilitic  Infection 56 

LESSON   VIL 
Varieties  and  Complications  of  the  Initial  Lesion  of  Syphilis 61 


13  CONTENTS. 

LESSON  VIII. 

FAQB 

Treatment  of  the  Initial  Lesion  of  Syphilis 66 

LESSON   IX. 
Early  Constitutional  Forms  of  Syphilis « 71 

LESSON  X. 
The  Treatment  of  Syphilis  in  the  Acute  Stage 81 

LESSON  XL 

Clinical  Cases,  Illustrative  of  the  Various  Forms  which  the  Initial 
Lesion  may  Present,  and  of  the  Various  Lesions  Associated 
with  and  Following  the  same 87 

LESSON  XIL 
Gangrenous  Initial  Lesion,  or  so-called  Phagedenic  Chancre 97 

LESSON  XIII. 

Polymorphous  Character  of  Syphilis  in  some  Cases  and  Absence  of 

Characteristic  Lesions  in  Others lOl 

LESSON  XIV. 
Mucoid  Form  of  the  Initial  Lesion 108 

LESSON  XV. 
Clinical  Case  Illustrative  of  the  Results  of  Treatment 118 

LESSON   XVI. 
Results  of  Tresitment— {Continued) 124 


CONTENTS.  13 

LESSON   XVII. 

PAca 
Sequelae  of  Syphilis 128 

LESSON   XVIII. 
Non-Contagiousness  of  the  Late  Lesions  of  Syphilis 167 


LESSON    XIX. 

Gummy  Tumor  of  Bone,  Loss  of  Substance  without  Caries — Syphi- 
litic Dactylitis 183 


LESSOM   XX. 

Syphilitic  Sequelae  Involving  Nasal  Bones,  Vomer,  and  Vault  of  the 

Hard  Palate 189 


LESSON   XXI. 
Gummy  Tumor  of  Bone,  Producing  Brain  Symptoms 193 

LESSON   XXII. 
Late  Brain  Lesions  of  Syphilis 199 

LESSON   XXIIL 
Syphilib  of  Infants  and  Hereditary  Syphilis 204 

LESSON  XXIV. 
Chancroid:  Its  Nature  and  Treatment 207 

LESSON   XXV. 
Nature  of  Chancroid — Contimied) ».  217 


14  CONTENTS. 


LESSON  XXVI. 

PAQK 

Does  Diagnosis  of  Chancroid  rest  upon  Character  of  Lesion  or  upon 

its  Source? 225 


LESSON  xxvn. 

Origin  of  the  Chancroidal  Abrasion ,.,.,,,  229 

LESSON  XXVIIL 
Chancroid  Modified  by  Condition , 236 

LESSON  XXIX. 
Diagnosis  and  Treatment  of  Chancroid 240 

LESSON   XXX. 

Diagnosis  and  Treatment  of  Chancroidal  Bubo  and  Bubonic  Chan- 
croid   250 


Remedies  and  Remedial  Agents  referred  to  in  this  Volume,   and 
their  Application , 258 


PRACTICAL  CLINICAL  LESSONS 


ON 


Syphilis  and  the  Genito-Urinary 
Diseases. 


LESSON  I. 


Nature  of  Gonorrhoea — Of  Chancroid — Of  Syphilis — Infective  Princi- 
ple of  Syphilis  a  living  Germinal  Cell — Its  History  dating  back  over 
2000  Years  B.C. — Syphilis  never  of  Spontaneous  Origin — Always  Ac- 
quired from  a  Human  Being  suffering  with  Syphilis — Always  Requir- 
ing a  Breach  of  Surface  for  its  Introduction — The  Virus  of  Syphilis 
not  an  Irritant — The  so-called  Incubation  of  Syphilis — Its  Practical 
Importance — Admixture  of  Syphilitic  Secretions  with  Vicious  Uterine 
Secretion  a  common  cause  of  error  in  Diagnosis — The  Initial  Lesion 
of  Syphilis  due  to  a  Localized  Cell  Proliferation — Not  Necessarily 
resulting  in  an  open  Lesion — Clinical  Cases  illustrative  of  the  Devel- 
opment of  the  Initial  Lesion  of  Syphilis — Treatment  by  Excision. 

Gentlemen  :  Through  the  light  of  modern  teaching 
and  experience,  we  recognize  three  separate  and  distinct 
contagious  diseases  resulting  from  venereal  contact; 
viz.,   Gonorrhoea,   Chancroid,  Syphilis. 

1st.  GoNORRHCEA. — A  vicious,  non-specific  inflamma- 
tion of  mucous  membrane,  characterized  by  free  puru- 
lent secretion  without  ulceration,  chiefly  occupying  the 
urethra  of  the  male,  and  the  vagina  and  urethra  of  the 
female ;  exceptionally,  the  mucous  surfaces  of  the  blad- 
der, the  eye,  the  nares,  the  rectal  and  buccal  cavities ; 
usually,  though  not  necessarily,  of  venereal  origin ;  its 
contagious  property  transferred  to  sound  mucous  mem- 
brane without  breach  of  tissue ;  its  action  immediately 
following   contact;    its  vicious   principle  incapable  of 


f8  PRACTICAL  CLINICAL  LESSONS  ON 

transmission  through  the  general  circulation;  its  occur- 
rence predisposing  to  subsequent  attacks. 

2d.  Chancroid. — An  acute,  contagious  ulcer  of  vene- 
real origin,  whose  contagious  property  is  incapable 
of  contaminating  the  blood,  and  hence  can  never  estab- 
lish a  constitutional  disease,  nor  be  acquired  by  hered- 
itary transmission ;  is  characterized  by  an  acute  ul- 
cerative action,  with  free  suppuration ;  is  commonly 
initiated  through  a  breach  of  surface,  but  possibly  oc- 
curs upon  sound  tissue ;  is  usually  multiple,  and  may 
occur  repeatedly  in  the  same  individual. 

3d.  Syphilis. — A  specific,  contagious,  constitutional 
disease,  caused  by  the  inoculation,  upon  any  part  of  the 
human  body,  of  a  peculiar  principle  or  contagium  called 
the  Syphilitic  virus ^  which,  after  an  indefinite  period  of 
apparent  rest,  or  so-called  incubation,  produces,  at  the 
point  of  inoculation  or  entrance  of  the  contagiiL7it^  a 
characteristic  lesion;  this  followed  by  another  period  of 
apparent  rest,  to  which  succeeds  a  group  of  well-estab- 
lished evidences  of  the  contamination  of  the  general 
system.  The  characteristic  initial  lesion  is  usually  soli- 
tary; sluggish,  and  non-suppurative  in  its  development; 
inoculable  with  difficulty  upon  the  person  bearing  it; 
and  as  a  rule  occurs  but  once  in  the  same  individual. 

During  the  course  of  clinical  lessons  which  we  inaug- 
urate to-day,  I  propose  presenting  to  you  cases  of  each 
one  of  the  above-named  diseases,  under  a  variety  of  cir- 
cumstances and  in  different  phases  of  their  development. 
However  ample  the  field  from  whence  clinical  cases  are 
drawn,  it  is  scarcely  possible  always  to  secure  such  a 
choice  as  will  permit  the  pursuance  of  a  rigidly  sys- 
tematic arrangement  in  their  presentation  ;  I  shall,  how- 
ever, endeavor  to  select  the  cases  so  as  to  show  you  the 
consecutive  manifestations  or  lesions  of  each  disease,  as 
far  as  circumstances  will  allow. 

To-day  I  purpose  presenting  to  you  a  number  of 
persons  exhibiting  one  or  more  phases  of  the  most  im- 
portant of  the  three  diseases  just  mentioned,  viz..  Syphi- 
lis. This  disease  is  produced  by  the  inoculation  of  a 
specific  virus  upon  any  part  of  the  human  body,  as  pre- 
viously stated.    Of  the  origin,  nature  or  composition  of 


SYPHILIS  AND  THE   GENITO-URINARY  DISEASES.      19 

this  virus — vital,  physical  or  chemical — we  know  prac- 
tically but  little. 

The  microscope  has  been  brought  into  requisition  by 
distinguished  experts  through  the  last  quarter  of  a  cen- 
tury, with  the  expectation  of  isolating  and  analyzing 
this  so-called  virus,  but  it  has  eluded  all  search.  Simi- 
lar investigation  as  to  the  origin  of  such  contagious  dis- 
eases as  variola,  vaccinia,  relapsing  fever,  and  the  cattle- 
plague,^  have  resulted  in  establishing  the  fact  that  a  de- 
generated, living,  germinal  cell  contains  the  infective 
principle  or  contagium,  the  so-called  virus,  through  which 
these  diseases  are  communicated.  Beale  was  the  first 
to  claim  that  a  similar  origin  would  be  found  for  syphilis, 
but  he  failed  to  make  the  actual  discovery.  As  we  pro- 
ceed, however,  it  will  be  found  that  much  valuable  cir- 
cumstantial evidence  will  be  met,  in  corroboration  of 
Beale's  view,  and  afford  a  possible  interpretation  of  the 
syphilitic  processes  in  harmony  with  recognized  physio- 
logical and  pathological  laws. 

Of  the  history  of  syphilis  so  much  has  been  written 
that  I  have  not  the  time,  if  I  had  the  inclination,  even 
to  epitomize  the  labors  of  syphilitic  historians.  I  will 
briefly  state  that  books  have  been  written  to  fix  its  ori- 
gin at  about  the  fifteenth  century,  attributing  it  to  the 
effects  of  excesses  in  camp  at  the  Siege  of  Naples,  1494 ; 
others  to  prove  that  it  originated  in  America,  and  was 
carried  to  Europe  by  Columbus  at  about  the  same 
period  ;  others,  again,  and  with  more  reason,  assert  that 
Moses,  the  great  Jewish  lawgiver,  knew  about  it;  and 
the  dispute  as  to  the  bad  eminence  of  having  originated 
syphilis  ran  high,  and  higher,  involving  poets,  historians 
and  doctors,  getting  up  no  end  of  bad  blood,  until  a  re- 
cent time  (1863),  when  a  Frenchman,  Capt.  Dabry  by 
name,  in  translating  a  very  ancient  record  of  Chinese 
medical  lore,  found  this  same  syphilitic  disease  thor- 
oughly described  in  its  various  stages  as  existing  and 
flourishing  over  two  thousand  years  before  the  Chris- 
tian era. 

Its  antiquity,  and  its  prevalence  to  a  greater  or  less 

*  Bcalc  on  the  Nature  and  Origin  of  Disease  Germs. 


20  PRACTICAL  CLINICAL  LESSONS   ON 

extent  in  every  known  country,  enable  us  safely  to 
affirm  that  it  has  not  been  from  lack  of  opportunities  to 
study  the  development  of  syphilis  that  its  constituent 
elements  are  unfamihar  to  us.  On  the  contrary,  it  has 
been  observed  with  probably  moi'e  care,  with  more 
scrupulous  nicety,  with  more  laborious  and  painstaking 
accuracy,  than  any  other  disease  with  which  the  human 
race  are,  or  ever  have  been,  afflicted.  It  has  not  only 
been  studied  and  observed  by  the  keenest,  the  most  eru- 
dite, the  most  profound  practitioners  and  philosophers 
the  medical  profession  has  ever  produced,  but  it  has 
been  the  altar  upon  which  not  a  few  have  offered  up 
their  own  bodies  as  subjects  of  scientific  experiment, 
throwing  health — even  Hfe  itself — into  the  investigation 
of  this  foulest  and  most  terrible  disease.  With  the 
great  John  Hunter  heading  the  list,  fully  half  a  score  of 
recorded  names  attest  the  courageous  self-abnegation, 
the  grand  enthusiasm  of  our  professional  brethren  in 
the  past,  whose  labors  and  sufferings  furnish  us  to-day 
with  all-important  and  indisputable  facts  concerning 
the  evolution  and  development  of  syphiUs.  Through 
such  earnest  investigations,  and  by  extended  observa- 
tion of  the  disease  as  accidentally  acquired,  it  has  been 
accepted — 

I  St.  That  syphilis  is  never  of  spontaneous  origin; 
that  no  emanations  from  natural  causes,  no  admixture 
of  diseased  conditions,  no  intermingling  of  necrotic  ele- 
ments, no  combination  of  vicious  indulgence,  is  capable 
of  establishing  this  disease  de  novo.  It  has  always  and 
invariably  as  a  starting-point  a  human  being  suffering 
with  syphilitic  disease.  Every  syphilitic  has  contracted 
his  syphilis  from  some  antecedent  syphilitic — has  re- 
ceived into  his  blood  a  virus  or  contagium  which  has 
circulated  in  the  blood  of  another  suffering  with  syphi- 
litic disease. 

2d.  That  for  its  introduction  into  the  human  system 
it  requires  a  breach  of  surface — a  solution  of  continuity  ; 
that  it  is  not  absorbed  through  sound  tissues;  that  it  is  not 
acquired  through  inhalation.  An  entrance  of  the  syphi- 
litic principle  always  requires  a  pre-existing  artificial 
port  of  entry.     This  may  be  accepted  as  an  unvarying 


SVPlilLiS  AND  THE  GEKlTO-tJRiNAkY  DISEASES.      21 

rule  as  regards  the  acquirement  of  syphilis.  The  child 
may  contract  the  disease  in  utero  from  the  diseased 
blood  of  the  mother.  The  mother  may,  it  is  claimed 
(not  proven),  become  infected  through  the  child  in  her 
womb,  diseased  by  the  influence  of  the  male  parent. 
These  possible  exceptions  do  not  invalidate  the  spirit 
of  the  law  requiring  a  breach  of  continuity  for  the  en- 
trance of  the  syphilitic  virus  into  the  human  organism. 

Though  the  constituent  elements  of  the  syphilitic 
virus  are  not  known,  this  much  we  do  know,  viz.,  that 
the  secretion  emanating  from  a  certain  well-recognized 
kind  of  sore, — which  we  call  the  chancre,  or  the  initial 
lesion  of  syphilis, — when  introduced,  by  the  aid  of  a  lan- 
cet, under  the  cuticle,  or  applied  to  an  abraded  surface 
anywhere  upon  a  healthy  individual,  produces,  after  a 
definite  period  and  with  absolute  certainty,  a  lesion 
presenting  similar  characteristics,  and  is  followed  by 
certain  other  evidences  of  a  contamination  of  the  system 
which  cannot  be  produced  by  any  other  known  agency. 

We  know  also  that  the  aforesaid  secretion  in  which 
the  virus  is  hidden,  when  free  from  extraneous  matters, 
is  of  a  bland,  unirritating  nature  in  its  local  action  upon 
living  tissues ;  that,  introduced  through  an  artificial 
puncture  or  an  accidental  abrasion,  it  gives  no  immedi- 
ate token  of  its  power — it  does  not  in  any  way  interfere 
with  the  natural,  rapid  and  complete  healing  of  the 
wound.  In  this  particular  there  exists  a  radical  differ- 
ence between  the  syphilitic  virus  and  that  of  the  local 
contagious  ulcer  called  the  Chancroid,  and  of  the  puru- 
lent secretion  of  a  Go7torrkcea ;  both  of  which  produce 
an  immediate  inflammatory  action  on  the  site  of  their 
initiation. 

Given,  then,  a  case  in  which  the  syphilitic  virus  has 
been  introduced  into  the  system  through  a  puncture  or 
an  abrasion  and  has  been  succeeded  by  a  complete 
healing  of  the  wounded  part,  let  us  consider  what  fol- 
lows. 

1st.  A  period  of  incubation,  so  called, — a  period  of 
apparent  rest ;  a  period  during  which  the  subject  of  the 
experiment  is  entirely  free  from  the  least  evidence  of 
the  introduction  of  the  poison  into  his  economy,  either 


S2  PRACTICAL   CLINICAL  LESSONS   ON 

at  the  point  of  inoculation,  or  through  any  constitutional 
disturbance  or  internal  or  external  sensation  of  any  de- 
scription whatever. 

No  feature  in  the  development  of  syphilis  is  of  more 
practical  importance  than  this  period  of  apparent  incu- 
bation. A  failure  to  appreciate  it  is  fraught  with  dis- 
comfiture to  both  physician  and  patient.  Lulled  into  a 
false  security  by  the  healing  of  a  lesion  following  an 
illicit  venereal  contact — even  assured  of  freedom  from 
disease  by  his  medical  adviser — many  an  unfaithful 
benedict  returns  to  his  marital  allegiance,  only  to  realize 
the  disaster  after  an  innocent  wife  has  been  infected  with 
syphilis,  and  through  her  the  disease,  it  may  be,  trans- 
mitted to  a  luckless  embryo. 

The  period  of  apparent  incubation,  according  to  au- 
thorities, varies  in  different  subjects  from  ten  to  seventy 
days.  The  causes  of  this  variation  are  not  well  under- 
stood. It  is  supposed  by  some  to  depend  upon  the  de- 
gree of  activity  of  the  particular  specimen  of  virus  in- 
oculated ;  by  others  upon  some  pecuhar  condition  or 
idiosyncrasy  of  the  subject.  The  fact,  however,  that  in 
the  great  majority  of  cases  of  experimental  inoculation 
of  the  virus,  from  whatever  source,  the  results  are  much 
more  uniform,  being  seldom  less  than  eighteen  nor 
more  than  thirty-five  days,  would  lead  to  the  belief  that 
other  influences  than  quality  of  the  virus  or  peculiarity 
of  the  individual  affects  the  term  of  apparent  incuba- 
tion. Experiments  in  regard  to  the  contagiousness  of 
non-specific  pus  have  demonstrated  its  erosive  property 
under  certain  conditions.  Secretions  from  a  diseased 
uterus,  and  even  from  the  Schneiderian  membrane,  are 
known  to  produce  excoriation  of  sound  mucous  tissues 
and  of  integument,  and  even  to  set  up  a  true  ulcerative 
process.  We  may  then  easily  admit  the  possibihty  of 
admixture  of  the  simple  non-irritating  secretion  from 
an  intra-vaginal  syphilitic  lesion  with  secretion  from 
a  diseased  uterus,  capable  of  effecting  a  solution  of 
continuity  in  sound  tissue ;  the  time  required  for  such 
an  effect  varying  with  the  degree  of  irritant  power 
and  the  condition  of  the  part  to  which  it  is  applied. 
Thus,   in   the   folds   of    integument    upon    the    penis, 


SYPHILIS   AND   THE   GENITO-URINARY  DISEASES.      23 

where  heat  and  moisture  are  at  the  minimum,  with 
even  a  decidedly  vicious  secretion,  many  days  might 
elapse  before  the  dry  cuticle  would  be  eroded  sufficient- 
ly to  afford  entrance  to  the  accompanying  syphilitic 
poison  ;  or,  on  the  contrary,  should  the  secretion  be 
applied  to  the  moist  delicate  lining  of  the  prepuce,  the 
solution  of  continuity  would  be  greatly  facilitated. 
Again,  in  case  of  fracture  of  the  skin  or  mucous  mem- 
brane, ulcerative  action  might  be,  set  up  coincidently 
with  the  vicious  contact;  and  yet  in  neither  case 
Avould  the  lesion  be  due  to  or  indicative  of  the  presence 
of  the  syphilitic  virus.  And  this  fact,  that  the  syphilitic 
virus  may  be  associated  in  the  same  individual  with 
vicious  uterine  secretions,  and  also  with  the  specific 
secretions  of  chancroid  capable  of  effecting  a  solu- 
tion of  continuity  in  sound  integument  or  mucous 
membrane,  naturally  leads  to  frequent  errors  in  diag- 
nosis. There  is,  I  repeat,  absolutely  nothing  in  the 
condition  of  the  patient,  at  the  point  of  entrance  of 
the  syphilitic  poison,  or  at  any  other  point,  which 
can  be  considered  a  proof  of  syphilitic  infection,  until 
the  termination  of  the  (so-called)  period  of  incuba- 
tion. And  this  time  is  announced  by  a  peculiar  change 
in  the  condition  of  the  tissues  at  the  point  of  entrance  of 
the  virus,  and  nowhere  else;  this  change,  too,  occurring 
equally  whether  an  abrasion  or  ulceration  has  been 
previously  established  at  this  point  by  other  causes,  or 
when  the  healing  has  immediately  followed  the  intro- 
duction of  the  virus.  An  exudation  or  development  of 
cellular  and  fibro-plastic  material  takes  place  in  the  tissue 
at  the  point  of  entrance  of  the  contagiurn;  and  this  pro- 
cess results  in  an  iyiduration  perceptible  to  the  touch,  and 
establishes  a  well-defined  characteristic  mark  of  syphili- 
tic infection.  This,  under  the  microscope,  is  found  to 
consist  of  lymphoid  or  germinal  cells  apparently  accu- 
mulated and  proliferated  in  loco,  as  a  direct  result  of  the 
syphilitic  inoculation.  The  excessive  localized  prolifer- 
ation of  cell  elements  constitutes  a  marked  feature  in 
every  stage  of  syphilis.  Its  first  appearance  at  the  site  of 
entrance  of  the  poison  forms  the  initial  lesion,  or  the  first 
positive  manifestation  of  the  syphilitic  influence.     The 


24  PRACTICAL  CLINICAL  LESSONS  OM 

course  and  duration  of  the  initial  lesion  varies  in  different 
subjects,  in  some  cases  appearing  as  a  nodule  covered 
by  sound  cuticle  or  mucous  membrane,  varying  from  a 
slight  increase  in  thickness  to  a  distinct  cartilaginous 
nodule  as  large  as  a  pea.  It  may  remain  stationary  for 
a  time,  and  then  terminate  in  resolution — that  is  to  say, 
undergoing  fatty  degeneration,  become  quietly  ab- 
sorbed ;  or  it  may  take  on  a  more  active  process,  in- 
volving the  destruction  of  the  overlying  tissue  and  an 
acute  disintegration  of  its  elements  ;  carrying  away  with 
them  a  certain  limited  amount  of  the  original  cellular 
tissue  involved  in  its  meshes,  and  producing  an  ulcer- 
like lesion,  but  which,  however,  is  independent  of  true 
ulcerative  action ;  its  secretion  thin  and  serous,  made 
up,  not  of  pus,  but  of  hastily  generated  cell  material ; 
its  natural  course  sluggish,  and  but  little  influenced 
by  local  treatment ;  healing  at  last,  over  the  induration, 
while  the  induration  continues  dense  and  characteristic, 
not  unfrequently  throughout  the  entire  course  of  the 
constitutional  disease. 

Some  of  the  points  of  interest  in  regard  to  the  incu- 
bation and  induration  of  syphilis,  which  I  have  briefly 
set  forth,  will  be  apparent  in  the  cases  which  are  now 
before  you.  From  the  first,  James-  B.,  aged  23,  we  glean 
the  history  of  an  exposure  about  the  13th  of  August 
last,  followed  by  a  soreness  of  the  "  bridle*'  or  frenum, 
which  lasted  for  two  or  three  days,  from  which  time 
nothing  especial  was  observed  until  the  second  week 
in  September,  when  he  noticed  a  *'  bunch"  in  the  loose 
tissue  of  the  frenum  which  became  chafed  about  a  week 
ago,  and  made  a  sore,  and  which  grew  gradually  larger 
up  to  the  present  time.  It  is  now,  as  you  can  see,  about 
the  size  of  a  threepenny  piece,  shallow  and  smooth, 
presenting  a  fine  granular  surface  with  but  httle  moist- 
ure. As  you  pinch  it  up  between  your  thumb  and 
finger,  the  induration  of  which  I  have  spoken  may  be 
distinctly  felt ;  and  I  present  this  case  to  illustrate  the 
history  of  its  origin,  and  which  is  classical  for  a  single 
variety,  and  that  you  may  test  the  induration,  which  is 
well  marked. 

In  Case  II.,  George  W.,  a  baker,  aged   19,  presents 


SYPHILIS   AND   THE   GENltO-URlNARY  DISEASES.     ^5 

three  points  of  apparent  ulceration,  one  upon  the  side 
of  the  frenum  about  the  size  of  a  split  pea,  and  two 
a  little  larger,  in  the  furrow  behind  the  glans  penis. 
George  has  no  distinct  remembrance  of  the  time  after 
exposure  when  these  sores  first  appeared,  but  thinks 
about  a  week  or  ten  days ;  has  had  them  about  a  fort- 
night ;  has  been  to  a  physician,  *'  who  burned  them  with 
caustic"  several  times. 

The  true  syphilitic  lesion  is  usually,  though  not  al- 
ways, solitary,  as  in  the  case  first  presented.  Here  the 
existence  of  three  points  of  lesion,  and  appearing  within 
two  days  from  exposure,  militates  against  the  idea  of 
their  syphilitic  nature.  You  will  also  remember  that 
the  characteristic  syphihtic  lesion  at  the  point  of  en- 
trance of  the  virus  is  seldom  less  than  1 5  or  more  days. 
There  is,  however,  a  distinct  induration  about  the  base 
of  these  sores,  little  if  any  less  than  that  which  you 
recognize  in  Case  I.  But  when  I  tell  you  that  simple 
sores  and  even  incised  wounds  become  indurated  by 
irritant  applications,  and  you  recall  the  patient's  state- 
ment that  these  have  been  "  burned  out  with  caustic," 
you  will  realize  the  difficulty  of  making  a  clear  diagnosis 
at  present.  We  will  advise  a  simple  water  dressing, 
and  if  the  induration  is  due  to  the  application  of  the 
caustic  it  will  soon  disappear. 

Case  III.  We  have  here  in  a  patient,  36  years  of  age, 
a  mass  of  induration  of  the  size  of  a  hickory-nut,  devel- 
oped in  the  tissue  of  the  inferior  portion  of  an  elongated 
prepuce.  Phymosis,  or  closure  of  the  preputial  orihce, 
has  resulted,  and  is  almost  complete.  He  complains, 
from  this  cause,  of  much  difficulty  in  passing  his  water. 
On  pressure,  a  gray,  serous-looking  fluid  exudes  from 
the  preputial  orifice  ;  a  shallow  excoriation  of  its  inner 
surface  is  observed  when  the  prepuce  is  strained  back. 
The  glands  of  the  groin  are  distinctly  enlarged,  but  pain- 
less ;  a  distinct  papular  eruption  covers  his  chest,  arms 
and  back.  The  history  of  this  patient  develops  an  ex- 
posure two  months  ago — not  for  a  month  previous,  and 
not  since.  Three  weeks  after  connection  he  noticed  a 
"  hardness,"  about  the  size  of  a  pea,  inside  the  prepuce, 
which  has  been  growing  ever  since.     He  has  had  no 


26  PRACTICAL  CLINICAL  LESSORS   ON 

trouble  from  it  except  the  pain  in  passing  water.  This 
case  appears  to  me  a  clear  one  of  syphilis.  If  the  indu- 
ration and  its  history  were  not  sufficient,  we  have  posi- 
tive proof  in  the  additional  evidence  furnished  by  the 
glandular  swellings  and  the  coppery  papular  eruption — 
the  significance  of  which  I  shall  have  occasion  to  refer 
to  on  a  future  occasion.  An  operation  is  here  called  for, 
to  remove  the  indurated  mass  on  account  of  the  phymo- 
sis  which  it  has  occasioned.  I  shall,  therefore,  proceed 
to  remove  the  entire  prepuce  by  the  introduction  of  a 
director  upon  the  superior  surface  of  the  glans,  and 
back  as  far  as  the  fossse ;  then  passing  along  it  a  curved 
bistoury,  I  bring  it  out  over  the  fossae  glandis,  and,  di- 
viding the  intervening  tissue,  remove  the  redundant 
mass,  including  the  induration,  with  a  single  cut  on 
either  side,  completing  the  incisions  at  the  frenum. 

You  will  observe  that  the  hemorrhage  here  is  very 
slight,  no  vessels  of  much  size  having  been  severed. 
Usually  there  is  quite  free  bleeding  from  the  vessels  of 
the  frenum,  in  such  case  requii'lng  ligature.  The  op- 
eration will  be  completed  by  bringing  the  cut.  surfaces 
into  apposition  with  a  very  fine  silk  thread,  by  the  glo- 
ver's' suture,  which  1  invariably  use  in  bringing  the  cut 
edges  together  after  a  circumcision. 


SYPHILIS  AND  THE   GENlTO-URlNARY  DISEASES.    ^7 


LESSON  11. 

Mon-Auto-inoculability  of  Chancre — Exceptional  Cases — Prevention  of 
Constitutional  Infection  through  Excision  of  the  Chancre  Denied — 
Rapidity  of  Infection  through  Germinal  Material  in  Proportion  to  the 
Rapidity  of  the  Cell  Proliferation  and  Size  of  Corpuscles  Diminishing 
in  same  Ratio — Syphilis  Characterized  by  Comparatively  Slow  Prolif- 
eration— Infective  Cells  in  Syphilis  not  necessarily  Differing  greatly 
in  Size  from  Normal  Germinal  Cells — Differing  only  in  Amount,  Pe^ 
culiar  Aggregation,  and  Characteristic  Infective  Property — Gross  Ap- 
pearances of  the  Excised  Chancre — Microscopical  Examination — 
Beisiadecki's  Observations  in  Twenty  Specimens — Confirmation  of  the 
Claim  that  the  Initial  Lesion  is  Formed  by  Cell  Proliferation,  iit  loco, 
and  not  the  Result  of  Inflammatory  Action — The  Open  Lesion  a  Legiti- 
mate Result  of  Interference  with  the  Vessels  of  Nutrition  from  Me^ 
chanical  Pressure  caused  by  the  Cell  Accumulation — Clinical  Cases 
Illustrative  of  Characteristics  of  Chancroid. 

In  briefly  characterizing  the  initial  lesion  of  syphilis, 
in  the  previous  lesson,  1  spoke  of  it  as  non-inoculable 
upon  the  person  bearing  it.  This  may  be  laid  down  as  a 
rule  where  the  Chancre  (as  this  lesion  is  usually  termed) 
has  not  been  subjected  to  irritation  sufficient  to  set  up 
a  purulent  discharge.  When  pus  is  present,  however, 
inoculation  may  result  in  an  ulcerative  lesion.  In  Case 
III.,  previously  cited  (p.  25),  the  lesion  was  apparently 
free  from  this  complication,  so  that  its  removal  will 
not  be  liable  to  inoculate  the  cut  surfaces. 

The  effect  of  removal  of  indurated  chancre  by  exci- 
sion has  been  the  subject  of  controversy,  some  authori- 
ties claiming  that  early  excision  of  the  initial  induration 
may  wholly  prevent  systemic  infection.  Auspitz  and 
Kolliker,  of  Vienna,  the  former  in  1877  ^i^^  the  latter  in 
1878,  reported  cases,  in  all  numbering  about  40,  where 
such  excision  was  believed  to  be  effectual  in  preventing 
the  occurrence  of  constitutional  syphilis.  It  was  even 
stated  that  in  several  of  these  cases  enlargement  of  the 
inguinal  glands  was  already  well  marked  at  the  date  of 
the  operation.  It  is  difficult  to  understand  how  such  a 
claim  can  be  seriously  advanced  when  there  is   such 


28  PRACTICAL  CLINICAL  LESSONS  0^ 

positive  proof  that  the  disease  has  already  involved  the 
l3^mphatic  system  beyond  the  site  of  the  initial  lesion ; 
and  when  we  consider  the  fact  that  the  inguinal  glands 
are  involved,  as  a  rule  to  which  there  are  few  excep- 
tions, by  the  time  the  induration  of  the  initial  lesion  is 
distinctly  recognizable,  we  must  deny,  absolutely,  even 
the  possibility  of  the  cure  of  syphilis  through  excision 
of  the  initial  lesion  alone.  It  is  now  beyond  question 
that  the  infective  principle  of  syphilis  entering  at  a 
given  point  gradually  invades  the  system — and  as  far 
as  we  are  able  to  trace  it  by  gross  appearances  and 
microscopic  examination  it  is  confined  to  the  lympha- 
tic vessels  and  glands  until  it  enters  the  blood  through 
the  great  lymph  channels.  Its  presence,  as  has  been 
previously  stated,  is  signalized  by  local  cell  accumula- 
tions, producing  the  characteristic  enlargement  and  in- 
duration, first  at  the  point  of  inoculation,  then  of  the 
adjacent  lymphatic  glands,  and  subsequently  of  every 
recognized  lesion  of  the  active  stage  of  the  disease. 
Inoculation  of  all  or  any  of  the  juices  or  secretions  of 
these  lesions  upon  healthy  persons  will  surely  communi- 
cate syphilis  to  such  persons.  Such  secretions,  under  the 
microscope,  are  found  laden  with  cell  material:  germ- 
inal matter  analogous  to  that  which  has  been  demon- 
strated by  Beale,  Chauveau,  Burdon-Sanderson  and 
others  to  contain  the  infective  principle  of  variola,  re- 
lapsing fever,  the  cattle-plague,*  etc.,  previously  re- 
ferred to.  The  rapidity  with  which  the  infective  ger- 
minal material  is  proliferated,  would  appear  by  the 
statements  of  the  authorities  just  mentioned,  to  be  in 
proportion  to  the  malignity  of  the  disease,  and  the  size  of 
the  infective  cells  or  corpuscles  to  diminish  in  the  same 
proportion.  It  is  not  then  remarkable  that  in  a  disease 
like  syphilis,  when  its  development  is  so  gradual  that 
months  elapse  before  its  climax  is  reached,  the  cell 
element  should  vary  but  little  from  the  normal  condi- 
tions. This  would  appear  to  be  not  improbable,  for  the 
closest  microscopic  investigations  have  failed  to  dis- 

*  Disease  Germs,  their  Nature  and  Origin.     Lionel   Beale.     London, 
1872.     Page  143,  etc. 


SYPHILIS  AND   THE   GENITO-URINARY  DISEASES.      2g 

tinguish  the  diseased  from  the  healthy  cell  material, 
and  it  is  only  by  its  abnormal  amount  and  peculiar  ag- 
gregation, together  with  its  infective  property,  that  it 
can  be  differentiated  from  the  most  healthy  germinal 
matter.  I  will  now  call  3^our  attention  to  the  gross 
physical  characteristics  of  the  initial  lesion  (Case  III.) 
just  removed  by  excision. 

It  has  exactly  the  appearance  and  feel  of  a  mass  of 
cartilage,  and  the  sensation  transmitted  through  the 
fingers  as  the  knife  is  drawn  through  it  is  the  same  as 
if  cartilaginous  material  were  divided.  There  is  no 
appearance  of  vascularity.  The  preputial  tissue  in 
which  it  is  imbedded,  and  in  which  it  is  freely  mova- 
ble, is  apparently  free  from  disease.  The  microscopi- 
cal examinations  of  such  indurations  show  that  they  are 
made  up  of  cell  accumulations  which  involve  even  the 
walls  01  the  blood-vessels,  and  bear  out  very  strongly 
the  claim  that  they  are  not  the  product  of  an  inflamma- 
tory process,  but  of  a  local  cell  proliferation  at  this 
point.  Alfred  von  Beisiadecki,  of  Krakow,  has  given 
us  the  results  of  a  very  exhaustive  microscopical  exami- 
nation of  twenty  specimens  of  this  variety  of  indurated 
tissue."^  He  says :  "  The  induration  consists  in  a  cell  in- 
filtration of  the  papillae  of  the  corium  and  subcutane- 
ous connective  tissue.  The  infiltrated  cells  are  similar 
to  those  of  dermatitis.  They  are  round,  have  one  or 
two  nuclei,  have  a  finely  granular  protoplasm,  and 
separate  the  connective  tissue  equally.  These  fibres 
retain  the  normal  size,  are  not  infiltrated  as  in  derma- 
titis ;  they  are  apparently  denser  and  more  resistant  to 
chemical  reagents.  But  the  arrangement  of  the  cells 
differs  from  that  in  dermatitis.  In  those  places  where 
a  rich  cell  proliferation  has  taken  place,  and  in  their 
vicinity  still  more,  we  find  that  the  neighboring  tis- 
sues of  the  vessels,  as  well  as  of  their  walls,  are  abund- 
antly infiltrated  with  cells.  The  walls  of  the  capillary 
vessels  of  the  papillae  are  thickened,  have  a  shining  and 
rigid  appearance,  and  enclose  Jiumerous  nuclei,  whicJi  pro- 
ject even  into  the  lumen  of  the  vessels.     The  adventitia  of 

*  Archives  of  the  Academy  of  Sciences  of  Vienna,  i867, 


30  PRACTICAL  CLINICAL  LESSONS  ON 

the  arteries  and  veins  is  three  times  its  normal  thick- 
ness, in  consequence  of  the  presence  of  numerous  round, 
spindle-shaped  and  branched  cells.  The  cahbre  of  the 
cells  is  diminished,  but  the  vessels  are  permeable.  If 
the  induration  still  increases,  we  find  in  its  vicinity  an 
abundant  proliferation  in  the  adventitia  of  the  vessels, 
and  subsequently  the  adjoining  connective-tissue  cells 
enlarge  and  proliferate  and  anastomose  with  those  situ- 
ated in  the  adventitia  by  means  of  their  processes." 

"  The  induration  is  explained,  however,"  he  further 
remarks,  "  neither  by  the  number  of  cells  nor  by  their 
peculiar  properties,  but  by  the  fact  that  while  in  derma- 
titis we  have  a  proliferation  of  cells,  and  also  a  serous 
exudation  which  infiltrates  the  tissues  and  fibres,  in  the 
induration  of  syphilis  we  have  a  dry  anseraic  tissue, 
resistant  connective-tissue  fibres,  considerably  thick- 
ened walls  of  vessels.  The  dryness  of  the  induration, 
which  produces  the  hardness  and  also  the  anaemia,  is 
caused  by  the  proliferation  in  the  walls  of  the  vessels, 
which  makes  it  difficult  for  the  serum  to  leave  the 
vessels,  and  also  diminishes  their  calibre.  And  this,"  he 
says,  ''explains  why  the  S3^philitic  induration  breaks 
down  into  a  molecular  mass,  and  why  resorption  takes 
place  so  slowly." 

Now,  in  contrast  with  the  indurated  tissue  associated 
with  and  characteristic  of  the  initial  lesion  of  syphilis, 
I  wish  to  direct  your  attention  to  another  patient.  Case 
IV.,  who  presents  a  sharply  defined  ulcer  occupying 
the  central  portion  of  the  fossse  glandis,  encroaching 
upon  the  glans  and  also  upon  the  reflexion  of  the  pre- 
puce. It  is  fully  as  large  as  a  dime,  and,  as  you  see, 
something  like  a  figure  8  in  form.  The  history  given 
by  the  patient  is  that  a  little  over  a  month  ago  he  had 
a  suspicious  connection,  and  within  a  few  days — he  is 
not  quite  certain,  but  not  more  than  five — he  observed 
"two  small  festers"  (pustules),  which  soon  discharged 
and  grew  until  they  formed  a  single  sore.  He  has 
made  repeated  applications  of  "blue-stone"  (cupri 
sulph.),  and  thought  he  was  getting  better,  when,  a  few 
days  since,  his  right  groin  began  to  be  swollen  and 
painful,  and  he  has  come  to  us  for  relief, 


SYPHILIS  AND  THE  GENITO-URINARY  DISEASES.      3 1 

On  pressing  this  ulcer  between  the  thumb  and  finger 
it  is  found  to  be  quite  free  from  hardness,  although  the 
caustic  treatment  to  which  it  has  been  subjected  would 
be  likely  to  develop  more  or  less  induration.  The 
edges  are  abrupt,  the  floor  is  irregular  and  covered 
with  a  yellowish  debris  composed  of  pus  and  dis- 
organizing tissue ;  the  surrounding  border  is  red  and 
somewhat  swollen,  and  also  quite  tender,  as  you  can 
observe  by  the  shrinking  from  our  very  careful  manipu- 
lation. We  have  here,  then,  judging  from  the  history 
and  appearance  and  condition,  a  characteristic  example 
of  the  contagious  venereal  ulcer,  previously  referred  to 
as  second  among  the  contagious  venereal  disorders,  and 
called  chancroid.  If  there  was  still  a  doubt  as  to  its 
nature,  it  is  dispelled  by  the  inflamed  and  swollen  con- 
dition of  the  right  groin.  We  recognize  by  gentle 
palpation  a  small  abscess  of  one  of  the  inguinal  glands, 
a  not  uncommon  result  of  the  chancroidal  action.  Pus 
from  the  chancroid,  gaining  access  by  ulceration  to  the 
interior  of  a  lymphatic  vessel,  passes  at  once  into  the 
gland  in  connection  with  it,  and  through  its  contagious 
and  destructive  property  goes  rapidly  on  to  the  pro- 
duction of  a  virulent  abscess,  the  pus  of  which  is  con- 
tagious and  destructive  equally  with  that  of  the 
chancroid.  The  chief  characteristic  of  the  chancroid, 
you  will  observe,  is  its  destructiveness.  It  begins  as  a 
pustule,  resulting  from  necrosis  of  tissue,  set  up  by  con- 
tact of  a  molecule  of  chancroidal  pus.  Throughout  its 
existence  its  secretion  furnishes  pus  which,  brought 
into  contact  with  healthy  tissue,  sets  up  a  destructive 
action  of  greater  or  less  activity.  It  is  simply,  only  and 
always  destructive,  and  without  the  destructive  prop- 
erty it  cannot  be  chancroid.  It  is  the  antithesis  of  the 
initial  lesion  of  syphilis,  which  in  its  inception  is  a 
process  of  growth  instead  of  dissolution,  and  in  which 
loss  of  tissue  occurs  not  by  any  virulent  agent,  but  by 
such  an  accumulation  of  new  material  as  to  embarrass 
and  finally  to  arrest  the  processes  of  nutrition,  and  in  this 
way  result,  in  instances  like  that  of  Case  III.,  in  an  open 
lesion.  The  microscopic  examinations  of  Beisiadecki, 
which  have  been  amply  verified  by  Auspitz,  Verspn, 
etc.,  prove  this  almost  beyond  question, 


32  PRACTICAL  CLINICAL  LESSONS  ON 


LESSON   III. 

The  Cell  Accumulation  of  the  Initial  Lesion  of  Syphilis  in  Harmony 
with  what  is  proved  to  occur  in  every  Lesion  during  the  Acute  Stages 
of  the  Disease — Cell  Proliferation,  iit  loco,  always  Sufficient  to  Explain 
Satisfactorily  the  Cause  and  Condition  of  the  Lesion — Gradual  Prog- 
ress of  the  Infected  Cells  through  the  Lymphatic  System  until  the 
General  Blood  Current  is  Reached — Practical  Denial  of  the  Views  of 
Instant  Infection,  with  Corroborative  Proofs — Incubation  of  Syphilis — 
Different  Modes  of  Transference  of  Syphilis— Most  frequent  Locations 
of  the  Initial  Lesion — Communication  by  Direct  Contact  through  the 
Act  of  Kissing,  through  Surgical  and  Gynecological  Operations,  etc. — 
Communication  of  Syphilis  through  Mediate  Contagion  or  through 
any  Material  which  has  been  in  Contact  with  the  Secretion  of  any 
Lesion  of  Active  Syphilis — Directions  for  the  Prevention  of  such  Acci- 
dents— Eight  Cases  Illustrative  of  this  Mode  of  Acquiring  Syphilis  by 
Medical  Men. 

The  sig-nificance  of  the  induration  in  the  initial  lesion 
of  syphilis  as  thus  explained  is  most  important,  and  will 
be  found  to  be  in  harmony  with  and  typical  of  each  and 
every  manifestation  or  lesion  throughout  the  active  or 
acute  stages  of  the  disease.  The  cell  accumulation 
which  has  been  demonstrated  to  constitute  this  indura- 
tion has  been  found  to  occur  in  the  lymphatic  vessels  in 
communication  with  it,  not  infrequently  recognized, 
like  knotted  cords  under  the  integument,  running  to  the 
lymphatic  glands  into  which  they  empty,  which  in  turn 
become  depots  for  the  prohferative  process,  and  enlarge 
in  the  manner  shown  in  Case  III.  (see  page  25),  and  are 
claimed  and  proven  to  be  characteristic  of  the  presence 
and  advance  of  the  syphihtic  disease.  The  induration 
associated  Avith  the  initial  lesion  of  syphihs,  then,  is  the 
result  of  a  gradual  invasion  of  the  tissues,  commencing 
at  the  point  of  inoculation  or  contact  of  the  syphilitic 
principle,  or  so-called  virus,  with  an  open  lesion  of 
the  integument,  or  mucous  membrane.  It  is  a  most 
significant  and  important  fact  that,  since  the  micro- 
scope has  been  applied  to  the  investigation  of  syphi- 
litic disease,  no  lesion  or  manifestation  of  it  has  failed 
to  present  evidences   of   cell   proKferation,  in  loco^  suf- 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.      33 

ficient  in  amount  to  explain,  in  a  satisfactory  way,  the 
cause  of  the  lesion.  It  has  also  in  the  same  manner 
been  demonstrated  that  this  localized  cell  proliferation 
and  accumulation  occurs  in  a  methodical  way,  progress- 
ing- steadily  from  its  point  of  beginning,  or  first  contact 
\vith  the  syphilitic  virus  or  principle,  gradually  invading 
the  lymphatic  vessels  and  glands,  until  it  reaches  the 
great  lymph  reservoir,  the  receptaculum  chyli,  through 
which  it  reaches  the  general  blood-current  by  the  sub- 
clavian veins.*  All  this,  it  will  at  once  be  seen,  is  in 
direct  opposition  to  the  views  formerly,  and  to  a  great 
extent  still,  held,  viz.,  that  the  virus  of  syphilis  enters 
the  blood  at  the  instant  of  inoculation,  and  that  thus 
*'  the  entire  organism  is  affected  at  once."'t'  Such  a 
claim  is  purely  theoretical  and  unsupported  by  a 
single  scientific  proof,  while  the  evidences  of  a  gradual 
infection,  through  the  lymphatic  system,  are  not  alone 
met  in  microscopical  examinations  by  distinguished 
scientists,  but  are  confirmed  by  the  clinical  observa- 
tions of  every  careful  observer ;  each  succeeding 
lesion  or  manifestation  from  the  initiation  to  the  termi- 
nation of  the  disease  adding  corroborative  proofs,  not 
only  by  its  physical  characteristics,  but  by  the  date  of 
its  appearance. 

THE   SO-CALLED   INCUBATION   OF   SYPHILIS. 

This  is  a  term  usually  applied  to  the  period  which 
elapses  from  the  date  of  inoculation  to  the  appearance 
of  the  characteristic  initial  lesion,  and  may  vary  in  dif- 
ferent cases,  according  to  different  authorities,  from 
one  to  seventy  days,  the  usual  time  being  from  ten  to 
twenty-five  days.  Strictly  speaking,  syphilis  has  no 
period  of  true  incubation,  inasmuch  as  the  process  of 
cell  proliferation  is  undoubtedly  established  at  the  mo- 
ment the  virus  (disease  cell  or  germ)  comes  in  contact 
with  the  germinal  or  white  blood  cell  of  the  human 
organism. 

*  See  Otis  on  the  Physiology  and  Pathology  of  Syphilis.     G.  P.  Put- 
nam's Sons.     New  York,  1881. 

f  Billroth,  Surgical  Pathology.     Am.  ed.,  p.  386. 


34  PRACTICAL  CLINICAL  LESSONS   OK 

The  immediate  effect  of  such  contact  seems  to  be  a 
rapid  increase  in  the  process  of  proliferation  of  such  of 
the  normal  white  blood  cells  as  have  become  contami- 
mated  or  degraded  by  the  influence  of  the  disease  germs 
(virus)  of  syphilis.  Through  accumulation  of  this  de- 
graded product,  the  tissue  (including  the  vessels  of  nu- 
trition) at  the  point  of  initiation  of  this  process,  becomes 
densely  packed,  forming  a  neoplasm  of  greater  or  less 
extent.  The  process  of  degradation  or  infection  is  con- 
fined to  the  immediate  locality  of  the  inoculation,  until 
the  degraded  cells  have  gained  access  to  the  interior  of 
a  lymphatic  vessel.  Through  this  channel  the  diseased 
cells  are  carried  to  the  nearest  lymphatic  gland  (the 
gland  of  connection^  as  it  may  be  termed),  and  here  are 
arrested,  by  the  peculiar  conformation  of  the  gland 
structure,  for  a  longer  or  shorter  period  (usually  about 
six  weeks),  during  which  time  there  is  no  further  evi- 
dence of  constitutional  infection. 

This  period  of  appare7it  rest  is  usually  termed  the 
second  incubation  of  syphilis. 

Note. — It  is  probable  that  the  interval  between  the  date  of  inoculation 
and  appreciable  gland  enlargement  is  dependent  upon  the  facility  or  dif- 
ficulty with  which  the  diseased  cells  gain  access  to  the  lymphatic  vessel 
connecting  the  point  of  inoculation  with  the  adjacent  gland.  Hence,  at 
points  where  the  distribution  of  lymphatic  vessels  is  most  liberal  and 
most  superficial  we  should  expect  to  find  the  shortest  interval  between 
inoculation  and  gland  implication.  This  view  is  supported  by  the  clini- 
cal fact  that,  in  cases  when  the  shortest  interval  occurs,  the  initial  lesion 
(in  the  male)  is  located  at  the  frenum,  or  the  anterior-inferior  surface  of 
the  glans  penis.  From  this  point,  chiefly,  the  superficial  lymphatic  ves- 
sels radiate,  and  are  (according  to  Balaieff)  ' '  most  stiperficial,  rising,  in 
this  especial  locality,  until  they  lie  just  underneath  the  epithelium"  (see 
Otis  on  the  Physiology,  Pathology,  and  Treatment  of  Syphilis  (Putnam 
Sons,  i8So),  pages  12  and  13,  where  it  is  shown  that,  by  direct  introduc- 
tion of  the  syphilitic  element  into  the  interior  of  a  lymphatic  vessel,  dis- 
eased action,  in  the  gland  of  connection,  is  inaugurated  at  once),, 


MODES   OF   TRANSFERENCE  OF   SYPHILIS   FROM  THE 
DISEASED   TO   THE   HEALTHY. 

The  modes  of  transference  of  syphilis  from  the  dis- 
eased to  the  healthy  are  three  : 
(i)  By  Direct  Contact  of  the  diseased  surface  with 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.      35 

an  abrasion,  or  other  breach  of  tissue,  on  a  healthy  per- 
son. 

(2)  By  Mediate  Contagion. 

(3)  By  Hereditary  Transmission. 
Communication  of  syphilis  by  Direct  CONTACT  fas 

under  the  circumstances  peculiar  to  the  venereal  act)  is 
the  most  frequent  mode  of  the  acquirement  of  syphilis. 
In  the  female,  initial  lesions  from  this  source  are  most 
common  in  the  vicinity  of  the  ostium  vagina ;  especially 
so  in  the  folds  of  mucous  membrane  about  the  foiirchette; 
between  the  greater  and  lesser  labice;  under  the  sheath 
of  the  clitoris ;  upon,  and  even  within,  the  meatus  urina- 
rius.  They  are  also  found  to  occur,  not  unfrequently, 
about  the  amis;  they  are  rarely  found  on  the  os  uteris 
and  still  more  rarely  on  the  vaginal  rugce. 

In  the  male,  the  most  frequent  sites  are  upon  \h.Q  glans 
penis  and  prepuce,  occurring-  with  especial  frequency  in 
the  sulci  by  the  side  of  the  frenum,  at  the  meatus  urina- 
rius,  and  in  the  fossce  glandis,  and  occasionally  on  the 
integument  of  the  penis. 

In  both  sexes  the  initial  lesion  is  sometimes  found  upon 
either  lip,  in  the  angles  of  the  mouth,  or  even  within  it, 
and  also  near,  or  within,  the  anus;  all  as  a  result  of  di- 
rect contagion.  Communication  of  syphilis  by  direct 
contact,  through  the  act  of  kissing,  is  an  accident  of  oc- 
casional occurrence.  There  is  also  a  danger  that  it  may 
be  transferred,  through  the  act  of  nursing,  from  syphi- 
litic infants  to  healthy  wet  nurses,  or  from  syphilitic 
nurses  to  healthy  infants.  Relations  between  nurses 
and  children  should  never  be  entered  into  without  a 
careful  consideration  of  this  fact.  In  these  cases,  the 
inoculating  secretion  may  be  furnished,  either  by  an 
Initial  Lesion,  or  by  one  of  the  common  manifestations  of 
active  syphilis,  known  as  the  Mucous  Patch. 

Initial  lesions  are  also  found  in  various  other  localities, 
as  solutions  of  continuity,  at  any  point,  may  become  the 
accidental  recipients  of  the  syphilitic  contagium.  Usually, 
they  are  rare  in  proportion  to  their  distance  from  the 
genitalia.  Surgeons,  accoucheurs,  and  gynecologists 
are  especially  exposed  to  the  peril  of  an  innocent  inocu- 
lation of  syphilis  by  direct  contact.     Within  the  circle 


36  Practical  clinical  lessons  on 

of  my  city  acquaintance,  at  the  present  time,  are  three 
medical  gentlemen  who  acquired  syphiHs  through  an 
initial  lesion  on  the  right  forefinger.  In  another  case, 
a  surgeon,  also  an  acquaintance,  received  the  syphilitic 
inoculation  in  the  end  of  his  right  forefinger,  through 
accidental  puncture,  by  a  spicula  of  bone,  while  ampu- 
tating the  leg  of  a  syphilitic  subject. 

Inoculation  of  Syphilis  through  Mediate  Con- 
tagion.— Cells  diseased  by  the  syphilitic  influence  (or 
what  is  usually  termed  the  syphilitic  virus)  may  cling  to 
substances  with  which  they  are  brought  into  contact. 
All  degraded  animal  cells,  or  disease  germs,  have  the 
power  of  maintaining  their  vitality  for  some  time  after 
removal  from  the  organism  in  which  they  have  been  de- 
veloped. (Beale.)  Any  material,  therefore,  which  has 
been  in  contact  with  the  secretions  of  syphilitic  lesions, 
or  the  blood  of  a  syphihtic,  during  the  active  stage  of 
syphilis,  may  prove  the  medium  of  communication  of 
syphilis  to  a  healthy  person,  provided,  only,  that  the 
substance  so  contaminated  is  brought  into  contact  with 
a  lesion,  however  slight,  of  the  skin  or  mucous  mem- 
brane. 

The  most  common  source  of  the  contagium,  in  cases 
of  Mediate  Contagion,  is  the  Mucous  Patch,  a  consti- 
tutional syphihtic  lesion,  frequent  upon  the  mucous 
membrane  of  the  lips,  mouth,  and  faucial  region,  in  per- 
sons passing  through  the  active  stages  of  syphilis.  The 
saliva  is  thus  impregnated  with  the  syphilitic  disease 
germs,  and,  through  it,  a  variety  of  domestic  utensils 
have  been  the  known  medium  of  syphilitic  inoculation, 
by  contact  with  abrasions  upon  the  lips  of  healthy  per- 
sons, without  regard  to  age  or  sex.  In  the  same  way, 
pipes  passed  from  syphilitic  mouths,  cigars  from  syphi- 
litic cigar-makers,  canes,  pencils,  and  even  sticks  of 
candy,  contaminated  by  syphihtic  saliva,  have  effected 
a  S37philitic  inoculation.  Within  the  last  eighteen 
months  I  have  met  with  four  cases  where  there  was  un- 
doubted proof  of  the  acquirement  of  syphilis  through 
mediate  contagion.  One,  of  a  young  lady,  with  the 
initial  lesion  on  the  lower  lip,  acquired  from  her  lover's 
kiss.     The  second,  a  physician,  with   the  initial  lesion 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.      3/ 

just  within  the  angle  (on  the  right  side)  of  the  mouth, 
from  a  syphilitic  friend's  pipe.  The  third,  in  the  same 
locality,  appearing,  characteristically,  about  three  weeks 
after  a  morning  spent  in  a  dentist's  chair.  The  fourth, 
a  worthy  merchant,  with  his  initial  lesion  (well  marked) 
on  his  lower  hp,  with  mucous  patches  in  his  mouth,  and 
an  accompanying  syphilitic  iritis.  In  this  latter  case 
the  only  clue  to  the  mode  of  acquirement  of  syphilis 
was  the  habit  of  passing  among  numerous  clerks  and 
occasionally  transferring  a  lead  pencil  from  their  desks 
to  his  mouth. 

Well-marked  constitutional  syphilis,  with  complete 
absence  of  any  genital  lesion,  was  present  in  each  case 
cited. 

The  foregoing  typical  cases,  illustrative  of  the  modes 
through  which  syphilis  may  be  contracted  by  Mediate 
Contagion  (with  the  exception  of  the  last),  were  seen  in 
consultation  with  physicians  from  neighboring  States. 
Such  accidents,  however,  are  of  more  likely  occurrence 
in  great  cities,  where  moral  restraint  is  least  stringent 
and  opportunity  for  acquiring  venereal  diseases  most 
favorable.  It  becomes  necessary,  therefore,  in  connec- 
tion with  cases  of  obscure  disease,  simulating  syphiHs, 
to  make  a  searching  scrutiny  of  all  incidents,  conditions, 
and  exposures  which  may,  in  the  light  of  possible  ac- 
cidents, point  to  opportunity  of  syphilitic  infection 
through  mediate  contagion.  The  third  case  cited  is  of 
especial  value,  as  conveying  a  lesson  on  the  necessity  of 
scrupulous  care  of  instruments  used  in  operations  about 
the  mouth. 

So  simple  a  procedure  as  the  depression  of  a  patient's 
tongue  with  a  spatula,  in  examinations  of  the  mouth  and 
throat,  may  easily  become  the  means  of  carrying  the 
syphilitic  disease  germ  to  an  abraded  surface  in  a  healthy 
person. 

In  all  cases,  therefore,  where  the  same  instruments 
are  in  use  for  different  persons,  after  thorough  cleans- 
ing, their  passage  through  the  flame  of  an  alcohol  lamp 
should  be  systematically  practised  after  every  opera- 
tion. The  same  procedure  is  equally  indicated  in  re- 
gard to  instruments  used  upon  other  mucous  membranes, 


38  PRACTICAL   CLINICAL   LESSONS   ON 

as  those  lining  the  urethra,  the  bladder,  the  rectum,  the 
eye.  It  is  also  essential  in  all  instruments  used  in  cut- 
tmg  operations  at  any  point.  Not  the  least  important 
among  the  modes  of  conveying  syphilis  by  mediate  con- 
tagion is  that  by  vaccination.  Numerous  well-authenti- 
cated cases  of  this  disaster  may  be  found  recorded  in 
any  modern  systematic  work  on  syphilis.  Inoculation 
of  syphilis  by  vaccination  may  be  effected  either  by  an 
impure  virus  or  an  unclean  knife.  Use  of  the  bovine 
virus,  by  means  of  a  clean  instrument,  relieves  this  benefi- 
cent operation  from  the  stigma  of  being  considered  a 
possible  means  of  communicating  sj^philis. 

Extract  from  the  Independent  Practitioner. 

EIGHT  CASES    OF   SYPHILIS  OF  THE  FINGER  IN  MEDICAL 
MEN.     REPORTED  BY  FESSENDEN  N.  OTIS,  M.D. 

Case  I.  W.  N.,  M.D.,  set.  26,  was  in  good  general  health  up  to  three 
weeks  ago.  In  the  latter  part  of  September,  1881,  he  noticed  a  small, 
red  papule  on  the  superior  surface  of  the  forefinger,  at  the  middle  of  the 
second  phalanx.  He  had  been  for  over  a  month  on  the  venereal  service 
of  Charity  Hospital.  He  had  never  noticed  any  previous  abrasion  at 
the  point  of  appearance  of  the  papule.  He  is  not  aware  of  having  had 
any  special  exposure  of  this  finger.  He  had  been  in  the  habit  twice  a 
week  of  making  vaginal  examinations  of  venereal  patients.  The  papule 
was  painless,  had  a  pale  red  color  and  a  slight  boggy  feel,  but  was  without 
distinct  induration.  Thinking  it  might  contain  a  splinter,  an  incision 
was  made  into  it,  but  no  splinter  was  found;  no  pus,  only  blood,  escaped. 
This  cut  remained  open  and  assumed  the  form  of  a  small  ulcer  with 
sharply  cut  edges,  y\  of  an  inch  in  diameter  and  y^g^  of  an  inch  in 
depth,  circular,  with  smooth,  shiny,  red  floor.  This  exuded  a  secre- 
tion which  accumulated,  dried,  and  formed  a  scab  which  dropped  off  at 
the  end  of  twenty-four  hours,  with  an  escape  of  3  or  4  drops  of  sero- 
purulent  fluid.  It  would  exude,  dry,  and  scab  over  again.  I  examined 
it  about  the  loth  of  November,  when  exudation  first  commenced,  and 
detected  in  connection  with  it  an  enlarged  and  somewhat  tender  gland 
in  the  axilla.  Several  days  after  I  found  an  enlarged  epitrochlear  gland 
in  the  right  arm.  A  deep  red  areola  with  a  scaly  border  now  surrounded 
the  lesion.  Patient's  health  was  good  up  to  three  weeks  ago  (or  six 
weeks  after  the  discovery  of  the  papule),  when  without  apparent  cause 
he  began  to  suffer  with  headache  and  general  malaise.  Insomnia  well 
marked;  appetite  pretty  fair.  He,  however,  kept  about  his  work  at  the 
hospital;  he  had  some  febrile  excitement;  temperature  about  100  in  the 
evening.  These  symptoms  all  disappeared  in  about  ten  days,  and  he  re- 
turned to  his  general  health,  and  was  feeling  perfectly  well,  when  on 
December  18,  looking,  as  had  for  some  time  been  his  habit  on  retiring, 
he  discovered  on  his  body  a  distinct  eruption  which  he  described  as  papu- 
lar in  character. 

Examination  at  the  present  time  (about  eleven  weeks  from  the  discoY' 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.      39 

ery  of  the  original  lesion)  shows  a  discrete  eruption  of  papules  both  fine 
and  coarse,  scattered  over  the  body,  most  prominent  on  the  chest  and 
arms,  and  pale  red  in  color;  also  distinctly  indurated  glands  in  cervical, 
epitrochlear,  and  inguinal  regions,  characteristically  enlarged,  and  one 
also  in  right  axilla  enlarged  and  tender.  The  throat  is  congested,  a 
single  scab  is  found  in  the  hair.  The  patient,  who  had  been  desirous  of 
waiting  until  the  diagnosis  of  syphilis  was  absolutely  certain,  was  now 
put  upon  a  systematic  treatment  for  that  disease. 

Case  II.  1878,  S.  S.  B. ;  presented  with  a  papule  of  the  middle  finger 
of  right  hand,  about  the  size  of  a  silver  three-cent  piece,  just  over  the 
second  joint,  elevated  and  non-suppurating.  It  appeared  as  a  red  spot 
about  two  weeks  previous,  and  has  gradually  become  elevated,  and  with 
no  distinct  induration.  About  six  days  ago  a  dry  scale  appeared  in  the 
centre  and  a  molecular  necrosis  started  from  that  joint.  He  has  poulticed 
it  for  the  last  week.  There  is  no  local  tenderness  but  some  pain  in-  the 
arm  stretching  up  from  the  lesion  as  far  as  the  elbow,  A  single  en- 
larged gland  is  found  in  the  corresponding  axilla  about  the  size  of  a  fil- 
bert. 

The  patient  was  advised  that  the  lesion  was  probably  syphilitic,  and 
instructed  to  wait  for  signs  at  other  points.  In  this  case  there  was  no 
positive  induration  about  the  lesion,  only  a  boggy  feel.  The  patient  has 
no  idea  of  any  date  of  exposure.  He  attended  a  confinement  on  April  6, 
but  had  no  suspicion  of  syphilis  in  the  case. 

I  lost  sight  of  this  patient  until  July,  1881,  when  I  was  informed  by 
Dr.  E.  F.  Ward,  of  New  York,  that  he  subsequently  had  roseola  and  a 
papular  eruption  developed,  and  that  he  was  at  this  time  suffering  from 
hemiplegia,  which  had  come  on  suddenly. 

Case  III.  In  latter  part  of  December,  1871,  the  patient,  a  physician, 
noticed  a  red  spot  upon  the  dorsal  surface  of  the  right  index  finger,  near 
the  base  of  the  second  phalanx.  The  spot  when  noticed  was  about  an 
inch  in  diameter,  and  continued  slowly  to  increase  in  circumference  and 
to  become  raised,  until  within  three  weeks  it  reached  nearly  the  size  of  a 
three-cent  piece  and  looked  precisely  like  a  vaccine  vesicle  without  a 
central  depression.  It  soon  became  incrusted,  but  by  the  application  of 
poultices  the  crust  was  removed,  leaving  a  well-rounded  ulcer  about  one- 
third  of  an  inch  in  diameter,  excavated,  clean,  without  discharge,  the 
edges  raised  and  all  of  a  deep  red  color  and  sluggish  in  appearance, 
neither  inclining  to  heal  itself  nor  to  yield  to  treatment.  The  base  was 
boggy  and  no  induration  whatever  could  be  discovered,  although  searched 
♦for  by  a  distinguished  surgeon  in  this  city,  and  by  him  the  lesion  was 
confidently  pronounced  to  be  at  most  2.  simple  chancre.  Another  surgeon 
familiar  with  syphilis  was  equally  confident  of  its  simple  character.  A 
third  who  saw  it  while  a  small  papule  regarded  it  with  suspicion,  and 
advised  the  patient  to  consult  some  surgeon  who  gave  especial  attention 
to  such  cases.  The  patient  then  came  to  me.  My  opinion  was  strongly 
in  favor  of  a  syphilitic  origin  for  the  lesion,  but  the  patient  desired  to 
wait  for  further  proof  before  commencing  constitutional  treatment. 
The  ulcer  showed  no  sign  of  improvement.  The  extended  finger  was 
bandaged  to  a  splint,  rendering  the  point  immovable,  and  allowed  to  re- 
main so  two  weeks,  but  without  improvement.  I  then  advised  the  appli- 
cation of  iodoform  powder.  Within  forty-eight  hours  a  decidedly  favor- 
able change  had  taken  place,  and  withm  ten  days  the  ulcer  was  perfectly 
healed.     Once  or  twice  afterward  the  skin  was  accidentally  broken,  but 


40  PRACTICAL  CLINICAL  LESSONS   ON 

on  reapplying  the  iodoform  it  healed  kindly.  From  the  first  appearance 
of  the  spot  till  the  healing  of  the  ulcer  no  pain  or  discomfort  was  felt. 
After  some  four  months — that  is  to  say,  in  the  following  April — the  doctor 
called  to  inquire  about  an  eruption  which  had  made  its  appearance  a 
week  or  two  previously  upon  his  breast  and  arm  chiefly,  sparsely  on  his 
face  and  head,  which  was  quite  bald.  The  eruption  was  of  a  dull  red 
color,  slightly  elevated,  and  several  papules  were  encircled  by  a  line  of 
exfoliating  epidermis.  They  were  free  from  itching,  and  were  discovered 
by  the  accident  of  their  appearance  on  the  face  and  scalp,  as  they  caused 
no  sensation  and  were  not  preceded  by  any  fever,  headache,  or  other  con- 
stitutional disturbance.  Examination  showed  distinct  gland  enlarge- 
ments in  the  cervical,  inguinal,  and  epitrochlear  regions.  He  was  then 
for  the  first  time  put  on  a  regular  mercurial  course,  viz.,  one  pill  of 
mass.  Hydrarg.,  2  gr.  combined  with  i  gr.  of  the  exsiccated  sulphate  of 
iron,  three  times  a  day.  At  about  this  time  this  patient's  wife  began  to 
complain  of  a  profuse  vaginal  discharge,  having  been  previously  in  good 
health,  and  free  from  any  leucorrhoeal  trouble.  About  three  months 
subsequent  to  this,  a  characteristic  papular  eruption  appeared  on  her 
face  and  body,  general  gland  enlargements  distinct  and  prominent  in 
groin,  neck,  and  epitrochlear  regions.  She  too  was  then  put  on  a  system- 
atic mercurial  course  similar  to  that  of  her  husband.  Both  were  kept 
under  treatment  for  about  a  year  and  a  half,  when  no  signs  of  syphilitic 
trouble  having  appeared  for  several  months,  it  was  discontinued.  To- 
da}'-,  Feb.  21,  1882,  the  doctor  reporting  by  my  request,  states  that  now 
nearly  ten  years  from  the  disappearance  of  the  disease,  and  the  cessation 
of  all  treatment,  both  he  and  his  wife  have  been  and  are  now  free  from 
any  evidence  of  syphilis. 

Two  other  cases  of  the  occurrence  of  syphilis  in  physicians  where  the 
initial  lesion  was  situated  on  the  right  forefinger  have  been  reported  to 
me  during  the  present  winter,  and  in  addition  to  these  I  am  cognizant 
of  three  other  cases  in  New  York  City,  two  gynecologists  and  one  dis- 
tinguished surgeon,  who  have  had  syphilis  through  an  initial  lesion  of 
the  finger. 

The  first  point  of  interest  in  considering  the  foregoing  cases  is  the  dan- 
ger to  which  any  physician  who  treats  diseases  of  females  or  attends  fe- 
males during  the  parturient  condition  is  more  or  less  exposed,  and  the 
necessity  of  using  extraordinary  precautions  in  examining  or  attending 
every  case  to  which  a  suspicion  of  syphilis  could  possibly  attach,  and  habits 
ually  to  protect  by  previous  application  of  elastic  collodion  any  cracks  or 
abrasions  about  the  nails  or  joints  of  the  fingers,  especially  of  the  right 
forefinger,  and  to  use  a  lotion  of  carbolic  acid  (i  to  100)  or  of  the  liquor 
potassa  permanganatis,  i  part  to  40  of  water,  as  a  habit  after  all  digital 
examinations  of  the  female  genital  apparatus. 

It  may  be  safely  asserted  that  a  pre-existent  abrasion  or  fracture  of  the 
skin  or  mucous  membrane  is  absolutely  essential  to  the  acquirement  of 
syphilis;  and  that  in  any  case  when  syphilis  has  been  acquired  without 
the  recognition  of  a  local  initial  lesion,  it  has  been  present,  but  over- 
looked. Destruction  of  tissue  is  not  essential  to  the  perfect  initial  lesion 
of  syphilis. 

Healing  of  an  abrasion  may  take  place  after  an  inoculation,  just  as 
promptly  and  as  perfectly  as  if  no  inoculation  had  taken  place,  and  the 
point  of  induration  following  may  be  so  small  and  insensitive  that  it 
would  easily  escape  observation. 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.     4I 

In  case  of  the  wife  of  physician  (Case  III.),  the  initial  lesion  was  not 
discovered.  Her  eruption  was  only  preceded  by  a  profuse  vaginal  dis- 
charge. There  was  never  any  recognized  open  lesion  on  the  penis  of 
her  husband.  It  might  be  said  of  her  that  the  inoculation  had  taken 
place  through  the  iniluence  of  the  semen.  Mireir,  of  Marseilles,  has  made 
repeated  experiments  of  inoculating  the  semen  of  a  person  in  the  active 
stage  of  syphilis,  upon  healthy  persons,  but  without  effect.  It  is  more 
probable — in  fact,  almost  a  certainty — that  the  disease  in  this  case  was 
acquired  from  a  syphilitic  papule,  of  which  there  were  at  one  time  several 
on  the  penis.  Abrasion  occurring  during  coition  coming  in  contact  with 
an  abrasion  of  the  os  or  vaginal  mucous  membrane,  might  there  establish 
the  initial,  lesion,  resulting  in  the  vaginal  discharge,  which  preceded  the 
syphilitic  eruption,  which  Was  the  first  recognized  evidence  of  syphilis  in 
the  doctor's  wife. 

The  second  point  of  interest  is  in  the  uniform  and  characteristic  physi- 
cal appearances,  presented  in  the  initial  lesion  of  syphilis  of  the  finger, 
coming  on  always  as  a  papule,  coming  soon  to  be  of  a  deep  red  color, 
and  presenting  a  superficial  abrasion,  becoming  circular  and  deeper  by  a 
slow  molecular  necrosis;  not  by  ulceration  with  formation  of  pus.  The 
secretion  thin  and  serous,  and  drying  into  a  scab  which  is  soon  dis- 
placed by  the  fluid  accumulating  underneath. 

The  entire  absence  of  induration;  in  its  place  a  slight,  fiat,  juicy-looking, 
boggy  swelling  or  elevation  about  like  a  small  peppermint  in  size  and 
thickness — early  appearance  of  an  enlarged  and  somewhat  tender  gland 
in  the  axilla  of  the  corresponding  side. 

I  would  like  to  call  attention  to  an  interesting  fact  in  regard  to  the 
efficacy  of  remedial  measures,  viz.,  that  in  five  of  the  above-mentioned 
cases  a  careful  systematic  mercurial  treatment  was  pursued  during  a 
period  varying  from  one  and  a  half  to  two  and  a  half  years.  Eight 
healthy  children  have  been  born,  and  both  they  and  the  parents  have 
continued  free  from  any  evidence  of  syphilis  up  to  this  date. 


42  PRACTICAL   CLINICAL  LESSONS   ON 


LESSON   IV. 

Syphilis  by  Hereditary  Transmission — Differences  of  Opinion  in  Regard 
to  the  Transmission  of  Syphilis  through  the  Spermaiazoids — Evidence 
Furnished  by  the  Cell  Theory  of  Syphilis  showing  the  Improbability 
of  Infection  in  this  Manner — The  Onus  of  Hereditary  Transmission 
Thrown  Upon  the  Mother — The  Previous  Acquirement  of  Syphilis  by 
the  Mother  Necessary  to  the  Infection  of  the  Foetus  or  an  Embryo — 
Syphilis  Transmitted  only  during  the  Active  Period  of  the  Disease; 
from  One  to  Three  Years — Reasons  for  this  Statement — Cases  Re- 
ported Claiming  a  Longer  Period  not  well  Substantiated — Without  a 
Contagium  there  is  no  Syphilis — Errors  Due  to  Acceptance  of  Imper- 
fect Evidence — Illustrative  Case. 


SYPHILIS    BY   HEREDITARY   TRANSMISSION. 

Heretofore,  in  considering  the  modes  of  transmission 
of  syphilis,  we  have  accepted  the  probable  fact  that  this 
disease  is  communicated  by  contact  of  a  diseased  with 
a  healthy  human  germinal  cell.  We  have  now  to  con- 
sider how  diseased  cells  in  the  adult,  male  or  female, 
suffering  with  syphilis,  may  be  brought  in  contact  with 
those  of  the  embryo,  or  of  the  foetal  organism.  It  is 
claimed  that  the  foetus,  through  the  natural  processes 
of  growth  and  development,  may  be  built  up  from  a 
syphilitic  seminal  animalculse  {spermatozoids)  furnished 
by  the  male,  in  conjunction  with  an  ovum  furnished  by 
a  healthy,  or  even  by  a  syphilitic,  female,  and  may  thus 
come  to  comparative  maturity.  Much  clinical  material 
has  been  adduced  to  prove  this.  On  the  other  hand  it 
is  claimed,  with  equal  proof  of  a  similar  character,  that 
this  is  never  the  case,  but  that  the  syphilitic  influence  is 
always  furnished  by  th.Q  female;  presumedly  communi- 
cated to  the  embryo  or  foetus  through  contact  with  the 
nutritive  elements  furnished  by  a  mother  in  whose  or- 
ganism the  degraded  cells  or  disease  germs  of  syphilis 
are  present. 

Like  most  important  questions  in  which  syphilis  is  in- 
volved, a  solution  of  the  foregoing,  based  on  clinical 
evideace  alone,  is  most  difficult.    The  best  proof  of  thi§ 


SYPHILIS  AND  THE   GENITO-URINARY  DISEASES.     43 

statement  is,  that,  on  either  side  of  all  such  questions, 
the  most  experienced  and  competent  observers  are 
ranged  in  nearly  equal  force.  To  constitute  Hereditary 
syphihs  either  the  embryo  or  the  foetus  must  be  infected. 
AH  infection  during-  or  subsequent  to  birth  must  be 
classed  with  one  or  other  of  the  modes  of  transmission 
of  syphilis  previously  considered. 

If  we  accept  the  syphilitic  influence  to  be,  as  pre- 
viously claimed,  a  degraded  formative  cell,  we  may  also 
accept,  as  a  legitimate  sequence,  that,  through  this  deg- 
radation, there  is  a  loss  of  formative  power — an  inabil- 
ity to  develop  into  any  useful  tissue. 

The  contagion  of  syphilis,  as  claimed,  is  always  ef- 
fected by  contact  of  a  degraded  with  a  Jiealthy  germinal 
cell.  In  a  strict  sense,  therefore,  it  is  always  locahzed. 
Cells  thus  degraded  are  practically  emasculated,  their 
capacity  for  usefulness  is  lost.  Of  necessity,  then, 
growth  of  living  tissue  occurring,  it  must  take  place 
through  the  normal  cell  elements,  that  is,  through  those 
which  have  escaped  this  degradation.  It  is  thus  plain 
that  only  a  portion  of  the  germinal  material  of  a  living 
organism  can  be  affected  by  syphilis.  Sufficient  germi- 
nal material  to  carry  on  the  processes  of  hfe  and  growth 
must  escape,  or  growth  would  be  at  once  arrested  and 
life  would  cease.  The  possibility  of  involving  in  the 
syphilitic  dyscrasia  so  infinitesimal  a  fraction  of  a  sper- 
matic organism  as  would  still  enable  it,  in  conjunction 
with  the  ovum,  to  play  an  efficient  part  in  the  growth 
and  development  of  the  human  embryo,  is  scarcely  con- 
ceivable. Especially  difficult  shall  we  find  it  to  accept 
such  a  view  when  we  consider  that,  once  in  connection 
with  the  ovum  the  syphilitic  influence  would  be  rapidly 
imparted  to  the  germinal  elements  furnished  by  //.  We 
may,  then,  consistently,  throw  the  great  improbabihty 
of  continued  growth  (or  indeed  of  any  growth),  under 
such  an  unfavorable  influence,  into  the  scale  with  the 
clinical  claims  of  those  who  deny  the  possibility  of  the 
embryo  or  foetus  being  infected  with  syphilis  by  the 
spermatozoids.  With  this  view  of  the  subject,  the  onus 
of  hereditary  transmission  of  syphilis  is  necessarily 
thrown  upon  the  Mother,  under  all,  even  under  appar* 


44  PRACTICAL  CLINICAL  LESSONS  ON 

ently  contradictory  clinical  circumstances.  Hence,  when 
an  embryo  or  foetus  is  the  subject  of  syphilitic  infection, 
we  may  conclude  that  it  is  the  result  of  contact  of  its 
normal  formative  or  germinal  cells,  with  cells  degraded 
through  the  syphilitic  influence,  furnished  by  the  nutri- 
tive fluids  of  the  mother ;  either  directly  through  the 
circulation,  or  through  degraded  cells  from  her  organ- 
ism, gaining  access  to  that  of  the  embryo  or  foetus  by 
their  amoeboid  power. 

Hence,  to  make  the  syphilitic  infection  of  an  embryo 
or  a  foetus  possible,  the  organism  of  the  mother  must 
first  be  infected  with  syphilis.  The  previous  acquire- 
ment of  S3^philis  by  the  mother  from  the  father,  or  through 
the  secretion  of  a  syphilitic  lesion,  or  from  the  blood  of 
one  suffering  from  active  syphilis  (by  direct  or  mediate 
contagion),  is  necessary  to  the  syphilitic  infection  of  a 
foetus  or  an  embryo. 

.  It  is  only  during  the  active  stages  of  syphiHs  (primary 
and  secondary  periods)  that  the  contagious  element  of 
the  different  lesions  of  syphilis  and  of  the  blood  is  pres- 
ent. Therefore  hereditary  transmission  of  this  disease 
is  only  possible  during  this  time  (usually  from  one  to 
three  years).  The  sequelae  of  syphihs  (tertiary  and  qua- 
ternary periods)  contain  no  discovered  elements  of  con 
tagion.  The  most  careful  microscopical  examinations 
have  failed  to  demonstrate  in  the  products  of  Tertiary 
Syphilis  (various  forms  of  guinmata,  including  eruptions) 
anything  besides  the  debris  of  normal  germinal  ele- 
ments. Repeated  inoculations  of  these  products  have 
failed  to  disclose  any  contagious  principle.  Without 
contagium  there  is  no  syphilis.  Hence  we  may  reason- 
ably conclude  that  hereditary  syphihs  is  only  acquired 
during  the  active  periods  of  the  disease,  and  that  in 
order  to  effect  syphilitic  contamination  of  the  embryo 
or  foetus  the  female  organism  must  first  be  infected. 

With  this  view  of  the  maternal  influence  in  syphilitic 
infection  of  the  foetus  or  embryo,  cases  reported,  claim- 
ing such  infection  to  have  occurred  through  the  sole 
agency  of  the  father  suffering  with  syphilis  (the  mother, 
up  to  this  time,  free  from  the  disease),  must  be  classed 
either  among  those  instances  where  the  characteristig 


SYPHILIS  AND  THE  GEnITO-URINARY   DISEASES.     45 

features  of  the  disease  are  absent,  or  where  they  are  so 
imperfectlj  developed  as  to  have  escaped  detection. 

The  difficulty  of  instituting  a  thorough  examination, 
under  circumstances  where  it  is  necessary  to  avoid  sus- 
picion of  its  object,  the  want  of  tact,  care,  and  experi- 
ence in  detecting  obscure  evidences  of  this  disease,  have, 
without  doubt,  too  often  led  to  the  acceptance  of  syphi- 
lis acquired  through  the  paternal  influence,  where, 
under  other  conditions  and  in  other  hands,  infection  of 
the  mother  would  have  been  recognized. 

The  following  case  will  serve  to  indicate  some  of  the 
various  ways  in  which  syphilis  may  be  overlooked,  and 
further,  to  show  important  variations  in  time  and  man- 
ner of  development  of  syphihs  from  a  similar  source. 
Some  three  months  since.  Dr.  W.,  a  naval  surgeon,  con- 
sulted me  in  regard  to  a  small  nodule  on  X\\q  fre?ium 
prepiitialis.  An  abrasion  was  discovered,  after  a  sus- 
picious exposure,  some  four  weeks  previous.  This 
healed  at  once,  as  if  simple,  and  nothing  further  was 
noticed,  until  the  nodule,  about  the  size  of  a  kernel  of 
pearl-barley,  was  observed.  Its  surface  was  abraded, 
probably  during  a  recent  connection.  Its  scanty  secre- 
tion was  found  under  the  microscope  to  consist  chiefly 
of  laminated  epithehal  scales.  On  account  of  the  obe- 
sity of  the  patient,  a  satisfactory  examination  of  the 
inguinal  glands  was  impracticable.  No  enlargement 
could  be  felt.  I  advised  excision  of  the  neoplasm.  This 
was  done  at  once,  and  healing  by  first  intention  was 
complete  in  forty-eight  hours. 

A  few  days  ago  (December  15th)  the  doctor  called  to 
say  that  the  operation  had  evidently  been  efficacious  in 
saving  him  from  a  general  syphilitic  infection  ;  that  he 
had  positive  proof  of  having,  himself,  communicated 
syphilis  to  a  young  lady  the  night  previous  to  the  ex- 
cision. In  her  case  an  initial  lesion  followed,  in  due 
time  after  the  connection,  accompanied  by  inguinal 
gland  enlargement  and  succeeded  by  general  gland 
hyperplasia.  She  now  had,  in  addition,  a  characteristic 
papular  syphilide,  and  yet  he  claimed  to  be  absolutely 
free  from  the  least  evidence  of  syphilis. 

A  cursory  examination  appeared  to  confirm  the  doc- 


46  I>RACTICAL   CLINICAL   LESSONS   ON 

tor's  statement.  This,  however,  appeared  so  improb- 
able, that  I  at  once  instituted  a  more  thorough  exami- 
nation, which  resulted  in  the  discovery,  under  a  deep 
layer  of  adipose,  of  small  but  characteristic  gland  en- 
largements in  connection  with  the  initial  lesion.  The 
cicatrix  on  its  former  site  was  slightly  indurated. 
Glands  at  a  distance — epitrochlean  and  post-cervical 
regions — perceptibly  enlarged.  Slight  but  positive 
congestion  of  the  fauces,  and  a  narrow  but  characteris- 
tic mucous  patch  hidden  behind  the  anterior  pillar  on 
either  side.  These  proofs  of  syphilitic  infection  had  es- 
caped the  anxious  search  and  skill  of  the  patient,  also 
of  a  professional  associate,  who  was  a  competent  and 
experienced  general  surgeon. 

Through  evidence  furnished  by  clinical  cases,  it  has 
been  claimed  that  syphilis  once  acquired  is  never  fully 
eliminated  from  the  system,  but  that  it  exists  as  a  pos- 
sible infecting  agent,  after  the  stages  which  furnish 
known  contagious  elements  are  past.  During  more 
than  twenty  years  of  observation  and  especial  interest 
in  regard  to  this  point  I  had  been  unable  to  find  a  sin- 
gle undoubted  example,  where  a  person  in  the  known 
Tertiary  period  of  syphilis  (and  so  demonstrated  by  the 
absence  of  the  glandular  enlargements  characteristic  of 
the  active  stages  of  the  disease)  had  been  the  proven 
carrier  of  syphilis  to  a  healthy  person.  I  came  to  be- 
lieve fully,  in  regard  to  persons  who  had  passed  success- 
fully through  the  so-called  p7'iviary  and  secondary  periods, 
and  so  proven  by  complete  absence  of  primary  and  sec- 
ondary hyperplasias  that  treatment  was  no  longer  neces- 
sary, that  such  persons  might,  if  desirable,  even  be  per- 
mitted to  marry,  with  the  assurance  that,  through  them, 
transmission  of  syphilis  to  wife  or  child  was  impossible. 
This  doctrine  I  had  taught  and  practised  for  a  very 
long  period,  when  a  case  came  under  my  observation 
which,  but  for  a  mere  chance,  had  unsettled  me  on  this 
vital  point  forever.  The  important  lesson  which  it  en- 
forced, namely,  to  distrust  the  value  of  purely  clinical  evi- 
dence,  may  be  profitably  transmitted  by  the  brief  extract 
from  my  note-book  which  follows: 

Mr.  Q.,  a  young  lawyer,  twenty-five  years  of  age,  had 


SYPHILIS  AND  THE   GENlTO-URlNARY  DISEASES.     47 

acquired  a  well-marked  initial  lesion  of  syphilis  on  the 
glans  penis.  His  gland  enlargements  in  the  epitroch- 
iean,  cervical,  and  post-cervical  regions  were  charac- 
teristic— his  roseola  escaped  observation,  but  a  classical 
papular  syphilide  appeared  about  the  fourth  month, 
and  continued  for  several  weeks.  Ulcerations  of  the 
tonsils  and  mucous  patches  on  the  soft  palate  and  inner 
surface  of  the  cheeks  followed,  but  yielded  satisfactorily 
to  treatment. 

The  gentle  but  persistent  use  of  mercury  internally 
and  by  inunction  had  been  pursued  from  the  first  and 
through  a  period  of  twelve  months,  occasionally  com- 
bined with  the  iodide  of  potassium.  At  this  time  all 
glandular  enlargements  had  disappeared,  except  a  small 
one,  the  size  of  a  pea,  in  the  right  post-cervical  region. 
Treatment  suspended  for  three  months,  when  a  thin 
diphtheric  patch  appeared  on  the  right  side  of  the 
tongue,  with  slight  induration.*  Treatment  resumed, 
mercury,  with  iodide  of  potash.  Patch  on  the  tongue 
faded  slowly  out  in  about  a  month,  but  was  replaced 
by  another,  on  the  opposite  side,  which  continued 
about  the  same  time,  cervical  gland  not  perceptibly 
changed.  A  series  of  mercurial  baths,  and  a  course 
of  Zittman's  decoction,  covering  nearly  three  months 
longer:  gland  now  scarcely  felt.  Patient  very  anxious 
to  marry,  but  was  advised  to  wait  a  full  year.  The 
next  six  months  passed  without  any  new  development. 
Gland  very  small,  but  still  recognizable,  when  the 
patient,  now  in  good  general  health,  married  on  his 
own  responsibility. 

One  year  after  marriage  the  wife  gave  birth  to  a  fine, 
healthy-looking  boy.  During  the  fifth  month  of  lacta- 
tion, the  wife  had  scrofulous  abscess  of  the  neck  (in- 
herited tendency),  which  alarmed  the  husband  (fearing 
syphilis)  exceedingly.  She  recovered  under  simple 
treatment,  and  relief  from  nursing.     Child  healthy  up 

*  I  have  known  patches  similar  in  appearance  to  result,  in  certain  cases, 
from  the  use  of  the  iodide  of  potassitim,  to  pass  off  when  the  remedy  was 
discontinued,  and  again  to  return  when  it  was  resumed,  I  have  also 
seen  patches  of  the  same  appearance  in  the  mouths  of  persons  habituated 
to  the  use  of  tobacco,  where  no  history  of  syphilis  could  be  ascertained. 


48  PRACTICAL  CLINICAL   LESSONS   ON 

to  third  year,  when  it  died  from  tubercular  meningitis, 
following  scarlet  fever.  No  salient  evidences  of  syphi- 
litic  taint.  Fear  that  his  old  trouble  had  been  in  some 
way  connected  with  his  child's  death  made  the  hus- 
band very  unhappy,  and  he  frequently  expressed  the 
fear  that  he  had  contaminated  or  might  yet  contami- 
nate his  wife,  to  whom  he  was  tenderly  attached. 

In  November,  1870,  Mr.  Q.  complained  of  some 
swelHng  and  soreness  over  the  right  tibia.  A  gummy 
tumor  was  found  presenting,  the  size  of  half  a  horse 
chestnut.  The  nature  of  it  explained,  he  was  put  on  a 
mild  mercurial,  with  large  doses  of  the  iodide  of  potas- 
sium, which  resulted  in  its  entire  disappearance  within 
a  month.  Both  husband  and  wife  continued  healthy 
up  to  October,  1871,  when  one  morning  he  called,  in 
great  distress,  to  say  that  his  wife  had  some  sores  in 
her  mouth,  resembling  those  of  his  early  syphilitic 
trouble.  I  did  not  hesitate  to  assure  him  that  this  was 
simply  impossible;  that  his  disease,  if  any  trace  of  it 
remained,  was  beyond  the  fear  of  contagion.  The 
spotless  character  and  chaste  deportment  of  his  wife 
made  me  sure  there  could  be  no  other  danger,  and  I 
comforted  him  accordingly. 

What  was  my  surprise,  on  seeing  her,  to  find  not 
only  several  characteristic  mucous  patches  in  her 
mouth,  but,  on  further  examination,  to  discover  four  or 
five  mucous  tubercles— one  on  the  inner  border  of  the 
thighs,  and  the  others  on  the  right  labium.  I  was 
forced  to  acknowledge  to  the  unhappy  husband  that  he 
was  right,  and  we  could  only  conclude,  contrary  to  all 
my  assurance  and  behef,  that  his  old  taint  had  been  the 
cause. 

Here  was  a  dilemma.  I  could  not  suspect  the  wife. 
I  could  not  accept  the  contagion  from  a  source  which 
stultified  all  my  conclusions,  teaching,  and  experience. 
I  was  wretched.  The  husband  was  wretched,  but  re- 
signed, desiring  only,  if  the  knowledge  of  it  was  not 
necessary  to  her  recovery,  that  I  should  keep  the  secret 
from  his  wife.  She  zvas  serene.  After  a  few  weeks' 
medication,  and  not  unfrequent  painful  applications  of 
caustic  to  the  mucous  tubercles,  I  thought  she  was  too 


SYPtllLIS  AND  THE  GENlTO-tfklNARY  DISEASES.     49 

serene.  I  asked  and  received  permission  from  the  hus- 
band to  tell  his  wife  what  her  trouble  was,  if  I  thought 
it  best.  My  manner  to  her  was  changed ;  from  being 
sympathetic  and  considerate,  it  became  brusque  and 
reserved.  An  explanation  was  finally  demanded.  I 
evaded  the  issue.  After  a  little  dexterous  fencing,  the 
source  of  her  troubles  was  flatly  claimed.  Ignorance 
of  my  meaning  was  feigned. 

I  explained  the  only  possible  causes  of  her  disease, 
and  said  she  had  been  married  too  long  to  suspect  her 
husband.  She  promptly  replied  that  he  was  ''as  pure 
as  the  sun."  I  then  told  her  if  she  would  give  me  her 
confidence,  I  would  protect  her — if  not,  would  lay  the 
matter  before  her  husband  (who  was  not  supposed  to 
be  aware  of  the  nature  of  the  disease).  Then  came 
tears — reproaches  —  and  finally,  in  a  tempest  of  wo* 
manly  indignation,  she  bade  me  leave,  forever.  I  left, 
disheartened  and  in  disgrace ;  but,  before  I  was  well 
on  my  way  downstairs,  I  was  recalled,  and  amid  tears 
and  sobs  she  confessed.  A  yachting  excursion ;  an 
unexpected  night  at  sea ;  exposure  with  an  old  lover : 
and  all  this  about  three  months  before.  A  letter  was 
subsequently  received  from  him  full  of  regret  that  he 
had  discovered  himself  syphilitic,  and  inquiring  if  he 
had  been  so  unfortunate  as  to  have  communicated  the 
disease  to  her. 

The  subsequent  progress  of  this  instructive  case  was 
not  peculiar.  The  lady  made  an  apparently  complete 
recovery  in  about  a  year.  After  another  year  she  again 
became  pregnant — was  delivered  of  a  healthy  child, 
now  living — but  died  of  puerperal  fever  the  third  week 
after  her  confinement. 

In  carefully  reviewing  this  history  it  will  be  observed 
that  while  it  is  seen  to  be  no  exception  to  the  rule  that 
tertiary  lesions  are  not  contagious,  it  will  show  how 
easily  they  may  achieve  the  credit  due  to  the  active 
manifestations  of  syphilis. 


50  PRACTICAL  CLINICAL  LESSONS  ON 


LESSON  V. 

Early  Differential  Diagnosis — The  Earliest  Recognizable  Evidence  of 
Syphilis  in  Local  Cell  Accumulation,  and  Progressing  until  Character- 
istic Nutritive  Disturbances  Occur — Neither  Inflammation  nor  Ulcera- 
tion Essential  Features  in  the  Results  of  SyphiUtic  Inoculation — 
Lesions  of  whatever  Kind  may  Receive  a  Syphilitic  Inoculation  and 
Heal  as  Quickly  and  Perfectly  as  if  no  such  Inoculation  had  Occurred 
— Immediate  Decision  in  such  Cases  impossible — Delay  until  the  long- 
est Interval  of  Known  Latency  between  Exposure  and  Development 
of  Syphilis  has  Occurred  necessary  to  a  Positive  Opinion  in  Cases  of 
Doubt — Induration  of  the  Initial  Lesion  Non-inflammatory — Inflam- 
matory Induration  Yields  to  Local  Treatment  which  renders  Specific 
Induration  more  Permanent— Physical  Characteristics  of  Specific  In- 
duration— Value  of '■  Confrontation"  in  Cases  of  Doubt — Cases  Illus- 
trative of  Danger  of  Mistaken  Diagnosis. 

EARLY    DIFFERENTIAL    DIAGNOSIS. 

The  characteristic,  and  only  constant,  feature  of  all 
lesions,  during  the  active  stages  of  syphilis,  is  shown  by 
microscopic  examination  to  consist  in  a  localized  cell 
accumulation. 

Consideration  of  the  nature  and  behavior  of  this  ma- 
terial will  afford  intelligent  aid,  in  a  differential  diag- 
nosis, between  the  initial  lesion  of  syphilis,  in  its  early 
period,  and  solutions  of  continuity  from  other  causes. 
As  far  as  shown,  syphilis  is  primaril}^  a  process  of  cell 
growth  and  accumulation,  so  rapid  that  it  interferes 
with  healthy  tissue  growth,  by  obstructing  the  processes 
of  nutrition  and  development.  Not  of  necessity  inter- 
fering to  the  extent  of  causing  death  of  tissue,  but  of 
impairing  its  vitality,  and  thus  causing  it  to  break 
down  more  rapidly  under  influences  which  favor  so- 
lutions of  continuity.  Hence  we  have  presenting,  as 
characteristic  initial  lesions  of  sj^philis,  either  a  neo- 
plasm, dense,  insensitive,  and  covered  with  unbroken 
and  apparently  normal  cuticle  or  mucous  membrane, 
or,  from  the  causes  above  mentioned,  some  one  of  the 
various  characteristic  solutions  of  continuity  associated 
with  the  initial  lesson  of  syphilis. 


SYPHILIS  AND   THE   GENITO-URINARY   DISEASES.      ^1 

In  addition  to  the  foregoing-  characteristic  lesions,  we 
may  also  find  early  local  disturbance,  in  various  forms 
and  from  various  causes,  associated  with  the  beginnings 
of  syphilitic  cell  accumulation,  but  presenting  no  feat- 
ures characteristic  of  syphilitic  inoculation. 

The  known  fact,  however,  that  syphilitic  infection 
not  unfrequently  follows  a  wound  of  inoculation,  which 
heals  promptly,  and  with  no  subsequent  solution  of 
continuity,  is  sufficient  to  prove  that  neither  Inflam- 
mation nor  Ulceration  are  essential  features  in  the 
results  of  a  syphilitic  inoculation. 

Thus,  wounds,  abrasions,  broken  vesicles,  pustules, 
or  ulcers  may  receive  a  syphilitic  inoculation,  and  pro- 
gress or  heal  as  if  no  such  inoculation  had  taken  place. 

It  is  then  evident  that  no  positive  differential  diagnosis 
can  be  made  at  once  between  lesions  which  will  be  fol- 
lowed by  syphilitic  infection  and  those  which  will  not. 
A  positive  decision  cannot  be  rendered  until  after  such 
interval,  from  latest  exposure,  as  may  be  required  to 
develop  some  characteristic  cell  accumulation,  either 
on  the  site  of  the  lesion  or  in  the  adjacent  lymphatic 
channels  and  glands. 

This  interval  is  recognized  by  all  authorities  as  a 
clinical  fact,  and  is  characterized  as  ^''The  Period  of  In- 
cubation of  Syphilis.'' 

The  term  was  invented  in  accordance  with  a  belief 
(formerly  prevalent)  that  the  virus  of  syphilis  was  a 
mysterious  impalpable  influence.  That  this,  having  en- 
tered the  system  at  a  given  point,  instantly  permeated 
the  fluids  and  solids  of  the  entire  organism.  It  then 
accumulated  by  ''  a  kind  of  germination"  until  the  point 
of  "  saturation^'  or  extreme  limit  of  tolerance,  was 
reached.  This  event  was  announced  by  a  peculiar  and 
characteristic  action,  at  the  point  of  entrance  of  the 
virus,  which  was  termed  the  Chancre. 

It  is  plain,  however,  that  such  a  view  of  syphilitic  in- 
fection can  have  no  support,  if  we  accept  the  view  of  a 
cell  degradation,  and  a  systematic  syphilitic  infection, 
in  accordance  with  known  histological,  physiological, 
and  pathological  laws. 

It  is  then  to  the  local  conditions,  at  the  point  of  inocu- 


52  PRACTICAL   CLINICAL   LESSONS   ON 

lation,  that  we  must  look  for  the  earHest  evidences  of 
syphilitic  action.  This  is  afforded,  at  first,  through  the 
microscope,  by  discovery  of  a  densely  packed  non-inflam- 
matory cell  accumulation  which  steadil}^  increases  until 
it  is  appreciable  to  the  ordinary  touch.  The  same  cell 
accumulation  is  also  seen  to  occur  in  the  lymphatic  ves- 
sels connecting  the  initial  lesion  with  the  adjacent  lym- 
phatic glands.  These  vessels  are  not  unfrequently  found 
obstructed  and  indurated,  and,  like  knotted  cords,  the 
size  of  a  crow's  quill  or  larger,  often  easily  traceable  to 
their  gland  termination.  The  associated  blood-vessels 
are  never  narrowed  or  interrupted  from  this  cause.* 

The  local  induration  of  a  suspected  lesion,  however, 
is  r\ot  positive  evidence  of  syphilitic  action.  Cell  accu- 
mulation sufficient  in  degree  to  produce  well-pronounced 
induration  may  result  from  irritation  of  a  simple  lesion. 
Thus,  an  herpetic  vesicle,  or  pustule,  even  a  simple  abra- 
:sion,  through  friction  from  clothes,  or  from  applications 
•of  caustics  or  astringents,  may  become  indurated  suffi- 
ciently to  raise  grave  suspicions  of  syphilis. 

Induration  in  such  cases  is  always  the  result  of  in- 
flammatory action. 

The  induration  of  syphilis  is  essentially  no7i-i7iflamma- 
tory.  The  differential  diagnosis  is  aided  by  means  used 
to  combat  the  inflammatory  condition.  Under  the  influ- 
ence of  rest  and  local  sedatives  the  incidental  induration 
is  promptly  dissipated;  in  the  initial  lesion  of  syphilis  \kiQ 
induration  is  made  more  salient.  Sometimes,  though 
rarely,  the  induration  is  quite  obscured  by  a  slight  local- 
ized serous  effusion,  which  gives  it  a  bluish  appearance. 
This  I  have  observed  in  several  cases  where  the  lesion 
was  on  a  finger.  The  same  condition  quite  frequently 
succeeds  well-marked  indurations  near  th.Q  fossa glandis, 
and  is  so  persistent  as  to  become  a  valuable  diagnostic 
mark. 

The  induration  may  be  said  to  be  characteristic  when 

*  The  only  recognizable  cell  accumulation  in  syphilis  is  confined  to  the 
15'^mphatic  system.  If,  during  the  period  of  so-called  incubation,  the 
syphilitic  influence  has  found  access  to  the  general  circulation,  no  evi- 
dence of  it  has  ever  been  discovered  in  the  condition  of  blood-vessels,  or 
of  the  blood,  or  in  the  conditions  or  sensations  of  the  person  so  affected. 


SYPHILIS  AND   THE   GENITO-URINARY   DISEASES.      53 

insensitive,  dense,  and  resistant,  like  cartilage.  If 
pressed  between  the  thumb  and  finger  it  becomes  ex- 
sanguinated, and  hke  in  appearance  to  the  tarsal  carti- 
lage, when  the  eyelid  is  turned  back. 

Even  this  most  positive  evidence  of  syphilis  cannot 
be  accepted  as  conclusive.  The  induration  of  a  com- 
mencing epithelioma  simulates  it  very  perfectly,  and,  if 
an  open  lesion,  its  secretion  under  the  microscope  pre- 
sents appearances  almost  identical.  In  summing  up 
the  whole  matter,  we  are  forced  to  confess  that  a  final 
decision  in  any  given  case  is  not  warranted,  until  some 
other  evidence  is  present  besides  the  appearance  and 
character  of  the  local  lesion. 

In  all  cases,  where  possible,  the  person  from  whom 
syphilis  rnay  have  bee7i  acquired  should  be  carefully  ex- 
amined. 

In  making  such  examination,  search  not  only  for  the 
initial  lesion,  but  for  each  of  the  possible  j^(;^;z^^rj/ mani- 
festations. Even  when  such  are  found,  it  must  be  borne 
in  mind  that  a  breach  of  surface  on  the  person  exposed 
is  essential  to  the  acquirement  of  syphilis,  and  that  this 
surface  must  be  brought  into  contact  with  the  syphihtic 
secretion,  either  directly  or  mediately.  So  that  while  the 
presumptive  evidence  furnished  by  confrontation  is  often 
strong,  it  is  not  necessarily  conclusive. 

The  following  cases  will  serve  to  illustrate  the  impor- 
tance of  caution  in  arriving  at  conclusions  in  regard  to 
the  true  nature  of  venereal  lesions  : 

Case  I.  Mr.  T.,  aged  twenty-three,  on  the  fourteenth 
day  after  his  first  and  only  connection,  noticed  a  sKght 
urethral  discharge.  Under  the  microscope  this  was 
found  to  be  distinctly  purulent.  No  pain  on  urination. 
Meatoscope  showed  the  mucous  lining  of  the  urethra 
deeply  congested  for  half  an  inch.  Beyond  this  there 
was  no  purulent  secretion  ;  appearances  normal.  The 
difficulty  was,  evidently,  not  go?torrhceal.  A  syphilitic 
inoculation  was  suspected.  Examination  of  the  woman 
with  whom  he  had  connection  showed  her  to  be  passing 
through  the  active  stages  of  syphilis.  No  initial  lesion 
was  found;  but  the  inguinal,  epitrochlean,  and  cervical 
glands  were  gbaracteristically  enlarged.    Several  mucous 


54  PRACTICAL  CLINICAL   LESSONS   ON 

tubercles  were  discovered  within  the  vulva ;  one  in  the 
cervical  sulcus,  and  three  on  the  os  tincce.  Besides  these 
there  was  a  double  row  around  the  anus,  eroded  and 
secreting  pus  freely.  In  the  presence  of  such  evidences 
of  syphilis,  it  seemed  impossible  that  the  young  man 
could  have  escaped  infection.  The  urethral  discharge 
was  probably  caused  by  a  syphiHtic  inoculation  which 
had  not  yet  produced  a  well-defined  initial  lesion.  Ingui- 
nal glands  of  both  sides  slightly  enlarged.  Treatment 
for  syphilis  deferred  (much  against  the  patient's  wish) 
until  evidence  of  syphilis  should  become  more  positive. 
The  urethral  discharge  gradually  declined  and  disappeared 
entirely  in  about  a  mo7ith.  Up  to  the  present  time  (four 
years  from  date  of  exposure)  patient  has  not  had  the 
slightest  evidence  of  syphilitic  trouble. 

Case  II.  Mr.  H.,  aged  thirty,  had  a  suspicious  con- 
nection in  May  last.  On  the  third  day  following  he 
noticed  several  small  pimples  on  his  prepuce.  Fearing 
venereal  disease,  he  consulted  his  family  physician,  who 
at  once  pronounced  the  trouble  a  simple  herpes.  A  mild 
lotion  was  recommended.  Under  its  use  all  evidences 
of  disease  disappeared  within  a  few  days,  and  the  patient 
was  assured,  in  the  most  positive  manner,  that  he  was 
free  from  disease.  June  loth,  four  weeks  after  the  sus- 
picious connection  (and  more  than  two  after  he  had 
been  pronounced  free  from  disease),  the  patient  was 
brought  to  me  by  his  physician  for  an  opinion  in  regard 
to  a  small,  hard,  eroded  nodule  on  the  former  site  of 
the  herpes.  Inguinal  glands,  on  corresponding  (right) 
side,  characteristically  enlarged.  My  belief  that  the 
nodule  was  an  initial  lesion  of  syphilis  was  strongly  ex- 
pressed, and  the  gentleman  was  put  upon  a  mercurial 
course.  A  month  later  he  called,  presenting  a  well- 
marked  roseola,  with  the  usual  secondar}'  gland  enlarge- 
ments. His  wife,  who  accompanied  him,  had  an  indu- 
rated initial  lesion  on  the  lower  border  of  the  meatus 
urinarius  and  well-marked  inguinal  enlargement. 

Case  III.  Mr.  W.  V.  No  unusual  trouble  until  two 
and  one  half  months  ago,  when  ten  days  after  a  suspi- 
cious connection  he  noticed  a  small  sore  on  the  right 
side  of  the  penis.     He  consulted  a  surgeon,  by  whom 


SYPHILIS  AND  THE   GENITO-URINARY  DISEASES.      55 

he  was  informed  that  he  had  a  ^^  soft  chancre;''  that  he 
would  quickly  destroy  it  by  application  of  nitric  acid, 
and  further,  that  there  needbeno  fear  of  subsequent  trouble. 
The  cauterization  was  made,  was  repeated  several  times, 
at  intervals  of  three  or  four  days  ;  healing  finally  taking 
place  in  about  three  weeks.  Patient  had  connection 
with  his  wife  the  night  previous  to  receiving  the  sur- 
geon's opinion  that  he  had  a  chancroid;  no  connection 
since. 

This  gentleman  called  upon  me  to  ascertain  the  cause 
of  apapulo-pustular  eruption  which  was  confined  to  the 
face  and  neck.  I  at  once  recognized  it  as  syphilitic ; 
examined  the  cicatrix  of  the  so-called  chancroid,  and 
found  it  distinctly  indurated.  Gland  enlargements  of 
elbow  and  neck,  all  well  pronounced  and  characteristic. 

In  answer  to  an  anxious  inquiry  as  to  the  possible 
infection  of  the  wife,  I  was  obliged  to  admit  the  possi- 
bihty  of  such  a  calamity.  He  assured  me  that  she  had 
been,  and  was  then,  perfectly  well  in  every  respect — 
"■  except  that  she  had  some  little  sivellings  in  the  right  groin; 
7iot  the  least  pain.''  An  examination  of  the  lady  on  the 
following  day  disclosed  characteristic  gland  enlarge- 
ments, not  only  in  the  groin,  but  in  the  arm  and  neck. 
No  search  was  made  for  the  initial  lesion.  She  was  put 
upon  constitutional  treatment  for  ^^  a  forin  of  leucocy- 
themia,"  and  remained  in  blissful  ignorance  as  to  the 
nature  of  her  own  and  her  husband's  trouble. 


56  PRACTICAL  CLINICAL  LESSONS  ON 


LESSON  VI. 

Progress  of  the  Syphilitic  Infection — Course  of  the  Disease  beyond  the 
Point  of  Inoculation — Infecting  Cells  Following  the  Course  of  the 
Lymph  Vessels  Carried  by  the  Lymph  Current  to  the  Lymphatic 
Glands — Detention  in  the  Glands  from  Mechanical  Causes — No  Evi- 
dence yet  of  Constitutional  Disease — Recent  Painless  Gland  Enlarge- 
ments Strong  Presumptive  Evidence  of  Syphilitic  Infection — Final 
Passage  of  the  Diseased  Cells  or  Germs  into  the  Receptaculum  Chyli, 
and  from  thence  into  the  General  Blood  Current — The  Period  Inter- 
vening between  the  Inoculation  and  the  Entrance  of  the  Disease 
Germs  into  the  General  Circulation  termed  the  Initiatory  Period  of 
Syphilis. 


PROGRESS   OF  THE  SYPHILITIC  INFECTION. 

The  term  Contagion  has  been  used  to  designate  the 
act  by  which,  through  cell  contact,  the  syphihtic  influ- 
ence is  conveyed  from  a  diseased  to  a  heahhy  person. 

By  means  of  the  influence  thus  communicated,  pro- 
Hferation  and  accumulation  of  degraded  cells,  at  the 
point  of  original  contact  (or  inoculation),  are  claimed 
to  result  in  the  establishment  of  the  initial  lesion  of 
syphilis,  or  cha^icre^  in  its  various  forms. 

The  course  of  the  disease  beyond  this  point  is  indi- 
cated, a  priori,  by  the  known  fact^  that  all  integumen- 
tary and  cellular  tissue  are  pervaded  by  lymph  spaces 
and  channels,  which  lead  more  or  less  directly  into 
lymphatic  vessels,  and  that  the  lymph  current  is  con- 
stantly flowing  from  the  tissues  toward  the  lymphatic 
vessels  and  the  glands  in  which  they  terminate. 

Therefore  a  degraded  germinal  cell  (syphilitic)  intro- 
duced into  the  tissues  (as  by  an  inoculation),  unless 
carried  directly  into  the  interior  of  a  blood-vessel,  must 
(itself,  or  its  vitiated  descendants)  of  necessity  sooner 
or  later  be  carried  along  by  the  lymph  current  to  and 

*  Strieker's  Human  and  Comparative  Histology,  Sydenham  ed.,  vol.  i, 
pp.  307  et  seq. 


SYPHILIS   AND   THE    GENITO-URINARY   DISEASES.      5/ 

into  the  gland  of  connection."^  All  clinical  observations 
confirm  this  view :  first,  in  the  discovery  of  indurated 
lymphatic  vessels  leading  from  the  point  of  inoculation 
to  the  gland  in  connection  ;  second,  by  the  subsequent 
enlargement  and  induration  of  such  glands ;  third,  their 
acceptance  as  a  necessary  sequence  of  the  inoculation, 
and  as  positive  proof  of  the  nature  of  the  disease. 

The  process  through  which  the  syphilitic  influence 
thus  gradually  advances  and  finally  invades  the  general 
system  is  termed  the  process  of  Syphilitic  Infection. 

The  progress  of  the  syphilitic  infection,  from  the  date 
of  its  genesis  at  the  point  of  inoculation  to  its  charac- 
teristic appearance  in  the  glands  nearest  the  point  of 
inoculation  (the  glands  of  connection),  varies  in  different 
persons,  from  causes  not  thoroughly  settled,  but  which 
are  indicated  in  note  on  page  96. 

The  degraded  cell  elements,  then,  effecting  an  en- 
trance into  the  substance  of  the  lymphatic  gland,  are 
here  detained  by  the  peculiarities  of  the  gland  struc- 
ture, and  perhaps  by  other  inhibitory  influences,  for  a 
period  varying,  in  different  instances,  from  twenty  to 
sixty  days.  This  period  is  recognized  by  all  clinical 
observers,  and  has  been  described  as  the  second  incuba- 
tion of  syphilis.  It  is  certain,  however,  that  no  syphi- 
litic influence  has  yet  been  discovered  in  the  general 
blood  current  during  this  period,  and  there  is  sufficient 
reason  to  suppose  that  the  diseased  elements  are  con- 
fined to  the  glands  of  connection,  and  those  intervening 
more  deeply  between  these  and  the  thoracic  duct.f 

*  "  The  wandering  red  blood  globules  mostly  again  return  into  the  cir- 
culation through  the  lymphatics.  The  wandering  white  blood  corpuscles 
f)robably  return  into  the  circulation  in  the  same  way."  —  Wagner's 
Manual  of  General  Pathology,  Am.  ed.,  p.  151. 

f  A  similar  inhibitory  influence,  exerted  by  the  lymphatic  glands  in 
cancerous  diseases,  is  cited  by  Virchow,  in  his  Cellular  Pathology,  Am. 
ed.,  p.  221,  with  the  following  explanation:  "We  can  account  for  this 
by  no  other  supposition  than  that  the  gland  collects  the  hurtful  ingredi- 
ents absorbed  from  the  breast,  and  thereby  for  a  time  affords  protection 
to  the  body." 

It  has  been  suggested  that  if  the  disease  were  really  so  localized, 
prompt  enucleation  of  the  initial  lesion  and  of  the  affected  glands  might 
prevent  general  infection.  It  must  be  remembered  that  the  infective 
cells,  each  of  which  is  potent  to  act  as  a  starting-point  for  systemic  infec 


58  PRACTICAL  CLINICAL  LESSONS  ON 

The  glands  of  connection  become  gradually  enlarged, 
apparently  through  the  proliferation  and  accumulation 
of  cells  in  their  interior. 

When  the  initial  lesion  is  located  upon  the  genital 
apparatus,  on  the  glands  or  on  the  body  of  the  penis  in 
the  male,  or  on  the  labile  or  within  the  vulva  in  the 
female,  the  lymphatic  glands  of  the  groin  become  en- 
larged, so  that,  as  a  rule,  several  may  be  distinctly 
recognized  by  the  touch,  varying  from  the  size  of  a 
small  pea  to  that  of  a  large  bean.  Sometimes  these 
enlargements  are  apparently  confined  to  the  side  cor- 
responding with  the  initial  lesion — sometimes  to  the 
opposite  side;  usually,  however,  the  glands  of  both 
sides  are  more  or  less  enlarged.  Hard,  nearly  or  quite 
painless,  and  movable,  their  gradual  accession  within 
two  or  three  weeks  after  a  suspicious  venereal  exposure  is 
strongly  indicative  of  syphilitic  origin,  without  regard 
to  the  character  of  the  local  lesion.  If  this  is  present 
and  indurated,  the  syphilitic  character  of  the  trouble 
is  no  longer  doubtful.  It  must,  however,  be  borne  in 
mind  that  glands  enlarged  through  the  influence  of 
scrofula  cannot  be  with  certainty  distinguished  from 
those  of  syphilitic  origin. 

They  are  found  in  the  same  locations,  and,  though 
usuall}'  less  positively  indurated,  are  still  sufficiently  so 
to  prevent  certain  diagnosis.  When  the  initial  lesion  is 
on  the  lips  or  in  the  mouth,  the  submaxillary  gland  is 
affected.    Wherever  situated,  it  is  always  the  glands  of 

tion,  are  not  only  present  in  untold  numbers  at  the  point  of  inoculation, 
but  that  (as  shown  by  Beisiadecki's  microscopic  researches)  the  walls  of 
the  intervening  lymphatic  vessels  are  lined  if  not  packed  with  them. 
Hence  any  proposed  surgical  extirpation  of  the  disease  must  imply  the 
entire  removal  of  all  the  lymphatic  connections  of  the  initial  lesion  and 
the  glands  of  connection.  A  procedure  not  only  without  sufficient  prom- 
ise of  benefit  at  this  stage  of  the  infection,  but  even  at  the  earliest  date 
after  inoculation,  the  necessary  ignorance  as  to  the  degree  of  implication 
of  the  lymph  spaces  and  vessels  in  the  vicinity  of  the  inoculation  would 
in  all  probability  render  all  such  means  of  preventing  the  spread  of  the 
infective  processes  of  uncertain  value. 

Early  excision  of  the  initial  lesion  may,  however,  be  found  to  modify 
the  intensity  of  the  subsequent  general  infection.  My  own  experience  in 
twelve  cases  of  excision  during  the  past  eight  years  would  warrant  this 
inference. 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.      59 

connection  {i.e.,  those  nearest  to  the  seat  of  inoculation) 
which  are  involved.  Such  enlargements  are  called 
syphilitic  buboes. 

The  complete  freedom  from  true  inflammatory  action 
which  has  been  shown  to  characterize  the  induration  of 
the  initial  lesion  of  syphilis,  and  the  lymphatic  vessels 
in  connection  with  it,  is  equally  characteristic  of  the 
enlargement  and  induration  of  the  associated  lymphatic 
glands.  When  attaining  sufficient  size  to  interfere  with 
freedom  of  motion  of  a  part,  or  where  from  any  cause 
they  are  subjected  to  undue  pressure,  a  degree  of  ten- 
derness may  result.  From  the  same  cause  inflamma- 
tion and  even  suppuration  may  occur  in  highly  scrof- 
ulous subjects.  Such  accidents,  however,  are  excep- 
tional, and  do  not  materially  lessen  the  diagnostic  value 
which  attaches  to  recent  and  painless  enlargement  of 
lymphatic  glands. 

The  progress  of  the  syphilitic  infection,  which  has 
been  steady  and  persistent  from  the  moment  of  inoc- 
ulation to  the  engagement  of  the  nearest  lymphatic 
glands,  appears  now  to  be  arrested.  Gradual  increase 
in  their  size  and  density  alone  indicates  the  activity  of 
the  infective  process,  until,  after  a  period  (varying  in 
different  instances  from  twenty  to  forty  days),  evidences 
of  constitutional  infection  may  appear. 

Access  from  the  surface  to  the  general  blood  current, 
through  the  lymphatic  spaces  and  vessels,  necessitates 
passage,  ist,  through  the  gland  in  immediate  connec- 
tion; 2d,  through  any  other  glands  or  vessels  which 
may  intervene  between  them  and  the  great  lymph 
channels ;  passage  from  thence  into  the  general  blood 
mass  is  immediate. 

Thus,  the  delay  between  appreciable  implication  of 
the  glands  of  connection  and  earliest  evidences  of  con- 
stitutional syphilis  is  explained  in  accordance  with 
known  histological  and  physiological  laws.  Hence,  it 
is  only  after  a  time  sufficient  for  the  passage  of  the 
diseased  elements  through  the  natural  barriers,  the 
lymphatic  glands,  to  the  general  blood  channels  that 
systemic  infection  can  take  place. 

With  this  view  oi\\iQ, progress  of  the  syphilitic  infection^ 


6o  PRACTICAL  CLINICAL  LESSONS   ON 

the  interval  between  the  date  of  inoculation  and  the 
introduction  of  the  diseased  elements  into  the  general 
circulation  may  be  appropriately  termed  the  initiatory 
PERIOD   OF  SYPHILIS. 


SYPHILIS  AND   THE   GENITO-URlNARY   DISEASES.     6l 


Lesson  vti. 

Varieties  and  Complications  of  the  Initial  Lesion  of  Svphilis— The  Indu- 
ratedPapule-2.  The  Dry  Scaling  Patch-3.  The  Chancrous  Abra<=ion 
-VThc  Saucer-shaped  Non-suppurating  Chancre  with  Indurated 
Base  and  Edge-5.  The  Elevated,  Moist.  \  elvety  Papule-Modmca- 
tions  of  the  rSregoing-i.  The  Mucoid  Chancre-2.  The  Inflamed  or 
Suppurating  Chancre-3.  The  Phagedenic  or  Gangrenous  Chancre- 
Modifications  of  the  Initial  Lesion  of  Syphilis  trom  Implantation  of 
Chancroid  or  other  Secretions  upon  it. 

(i)  The  initial  lesion  of  svphilis  begins  by  a  process 
of  Undue  Growth  and  ^Iultiplication  of  normal 
P-erminal  cells,  induced  bv  contact  (through  a  lesion  ot 
mucous  membrane  or  integument;)  with  Diseased  or 
Degraded  cells  derived  from  a  person  suffering  Irom 

Svphilis.  ,  ,         .  ,     r 

h)  Cells  thus  generated  accumulate  at  the  point  ot 
initiation,  in  a  circumscribed  portion  of  the  surrounding 
and  underlving  tissue,  and  also  in  the  walls  and  interior 
of  the  blo6d  and  Ivmph  vessels  of  the  tissue  so  impli- 
cated, and  thus  form  a  characteristic  neoplasm  which 
is  termed  the  Liifui/  Lesion  of  Syphilis— oi  which  there 
are  live  characteristic  forms,  namely : 

(i)  The  Indurated  Papule. 

(2)  The  Drv  Scahng  Patch. 

ii)  The  Chancrous  Abrasion. 

(4)  The  Saucer-Shaped  Non-Suppurating  Chancre, 
with  indurated  base  and  edge. 

(5)  The  Elevated,  Moist,  Velvety  Papule. 
And  as  modifications — 

The  Mucoid  Form. 

The  Inflamed  or  Suppurating. 

The  Phagedenic  or  Gangrenous. 

Also  modifications  arising  from  implantation  of  the 
Virus  of  Chancroid  or  other  Vicious  Secretion,  upon  the 
Initial  Lesion  of  Syphilis  of  any  one  of  the  above-named 

forms.  ,        .  J     ^ 

The  initial  lesion  of  syphilis  may  be  situated  at  any 


62  PRACTICAL  CLINICAL  LESSONS  ON 

point  on  the  surface  of  the  body,  or  it  may  be  concealed 
within  the  orifice  of  the  meatus  urinarius,  the  anus,  or 
the  mouth. 

The  differences  in  form  of  the  initial  lesion  of  syphilis 
are  the  legitimate  and  direct  results  of  interference,  to 
a  greater  or  less  degree,  with  the  circulation  of  the  tis- 
sues, at  or  beneath  the  point  of  initiation,  of  the  abnor- 
mal cell-growth.  Thus,  in  regard  to  the  first-named 
form  : 

(i)  The  indurated  papule  is  a  dense  neoplasm  in  the 
cellular  tissue,  movable  under  the  skin,  and  hence  not 
materially  impeding  its  functions.  Complete  absorp- 
tion of  this  morbid  growth  may  take  place,  and  the 
organism  become  thoroughly  contaminated  with  syphi- 
lis, without  the  occurrence  of  any  open  lesion. 

(2)  The  dry  scaling  patch  always  occurs  upon  integu- 
ment, and  the  cell  accumulation  is  diffused  and  quite 
superficial,  producing  an  induration  which  to  the  touch 
is  like  parcJimeiit ;  hence  the  term  '■^parchment  indura- 
tion'' applied  to  this  lesion.  Interference  with  the 
circulation  in  this  case  is  not  sufficient  to  prevent  the 
evolution  of  the  epidermis,  but  its  development  is  im- 
peded, and  layers  of  dry  epidermic  scales  cling  to  its 
surface,  giving  it  a  characteristic  scaly  appearance. 

(3)  The  chancrous  abrasion  occurs  upon  an  indurated 
papule,  which  by  peripheral  cell-growth  has  come  to 
involve  the  circulation  of  the  cutaneous  or  epithehal 
structures  to  the  extent  of  rendering  them  friable  and 
easily  abraded.  Imperfect  evolution  of  the  underlying 
cell  elements  results  in  a  free  shedding  of  the  superficial 
layers  from  the  moist  surface  of  the  lesion.  Under  the 
microscope  these  are  seen  to  be  like  laminated  epithelial 
scales,  and  constitute  a  significant  mark  of  chancrous 
abrasion. 

(4)  The  saucer-shaped  non-suppurating  chanci*e,  with 
indurated  base  and  edge.  In  this  form  a  characteristic 
loss  of  tissue  has  taken  place  (almost  entirely  at  the 
expense  of  the  adventitious  cell-growth),  through  the 
continuance  and  extension  of  the  causes  which  produce 
the  chancrous  abrasion;  loss  of  tissue,  as  in  that  case, 
also  occurring,  not  through  the  suppurative  or  ulcera- 


SYPHILIS  AND   THE   GENITO-URINARY   DISEASES.    63 

tive  process,  but  by  that  which  Virchow  has  termed  a 
necrobiosis  (death  from  altered  life),  that  is,  from  a  grad- 
ual obstruction  to  the  processes  of  nutrition  of  the 
affected  part.  The  secretion  of  this  form  of  initial 
lesion  is  scanty,  free  from  pus,  and  presents  under  the 
microscope  the  squamous  epithelial  elements  found  in 
the  secretion  of  the  chancrous  abrasion. 

(5)  The  elevated,  moist,  velvety  papule,  is  neither 
more  nor  less  than  the  previously  described  lesion, 
"  The  saucer-shaped  non-suppurating  chancre,  with  indu- 
rated base  and  edge,''  upon  which  the  granulation  tis- 
sue of  Billroth  has  been  developed.  This  tissue  is 
described  in  Billroth's  "  Pathology,"  Am.  ed.,  p.  93, 
under  the  head  of  "'Proliferating  fungus  granulatio7isy 
He  says,  ''  The  most  frequent  cause  of  the  development 
of  such  granulations  is  any  local  impediment  to  healing, 
such  as  rigidity  of  the  surroimding  ski7i,  so  that  the  con- 
traction of  the  cicatrix  is  difficult."  This  rigidity  in 
the  case  of  the  moist  velvety  papule  is  caused  b}^  the 
characteristic  induration  of  syphilis,  always  associated 
with  this  form  of  initial  lesion. 

We  shall  consider  next  the  modifications  to  which  the 
different  forms  of  initial  lesions  are  subject. 

(i)  The  mucoid  chancre,  is  that  modification  of  the 
moist  velvety  papule,  which  arises  from  the  occurrence  of  a 
diphtheritic  membrane,  or  deposit,  upon  its  surface,  giv- 
ing it  the  appearance  of  that  secondary  or  constitutional 
manifestation  of  syphilis  known  as  the  mucous  papule. 
This  modification  usually  takes  place  coincidently  with 
the  appearance  of  mucous  papules  or  patches  in  other 
localities.  The  induration  associated  with  the  initial 
lesion,  thus  modified,  and  its  entire  absence  in  the  mu- 
cous papule,  will  constitute  the  distinguishing  difference 
between  these  lesions. 

(2)  The  infiamed  or  suppurating  chancre.  In  any 
of  the  open  initial  lesions  subjected  to  persistent  irri- 
tation from  friction  of  clothes,  repeated  coition,  appli- 
cation of  caustics,  alcoholic  excess  (especially  in  the 
scrofulous  and  debilitated),  an  inflammatory  action  may 
be  set  up.  This  soon  results  in  pus  formation,  and 
a  more  or  less  active  necrosis,  so  like  in  character  to 


64  PRACTICAL   CLINICAL   LESSONS   ON 

that  occurring  in  chancroid,  that  errors  in  diagnosis  are 
easy.  The,  now  purulent,  secretion  of  the  chancre  is 
found  to  be  contagious,  producing  by  auto-inoculation 
a  sore,  identical  with  true  chancroid,  thus  further  ob- 
scuring the  differential  diagnosis.  Previous  history, 
and  the  induration  more  or  less  distinctly  marked,  will 
usually  be  sufficient  to  indicate  the  true  character  of 
this  lesion. 

(3)  The  phagedenic  or  gangrenous  chancre.  In 
certain  cases  of  the  inflamed  or  suppurating  initial 
lesion  the  indurated  tissue  becomes  livid  in  color  quite 
suddenly,  and  exhales  a  peculiar  sickening  odor,  an- 
nouncing the  occurrence  of  gangrene.  This  results 
from  arrest  of  the  vascular  supply  to  the  induration, 
through  an  aggravation  of  the  causes  which  led  to  the 
antecedent  necrobiosis.  This  view  is  sustained  by  the 
known  influence  of  mercury  in  arresting  the  destruct- 
ive process  thus  set  up  in  the  initial  lesion,  while 
in  any  other  form  of  gangrene  the  influence  of  this 
drug  is  known  to  be  pernicious,  and  also  from  the  fact 
that  the  loss  of  tissue  is  usually  limited  to  the  indu- 
ration. When  the  death  of  tissue  occurs  by  molecular 
continuit}^  the  lesion  is  said  to  be  Phagedenic  ;  when 
the  induration  sloughs  out  en  masse  it  is  called  GANGRE- 
NOUS. The  influences  which  tend  to  convert  the  in- 
flamed or  suppurating  initial  lesion  into  the  phagedenic 
or  gangrenous  are  predisposition  to  suppuration  front 
any  cause,  constitutional  dyscrasia,  alcoholic  excess,  low, 
irregular  life,  etc. 

All  forms  of  the  initial  lesion  in  syphilis  may  be  modi- 
fied and  more  or  less  obscured  by  the  occurrence  of 
ulceration  from  any  cause  upon  the  site  of  syphilitic 
inoculation. 

No  surface  changes  at  the  point  of  entry  of  the  syphi- 
litic virus  or  principle  can  affect  the  course  of  the 
syphilitic  infection  after  the  disease  germ  has  passed 
into  lymph  channels  (spaces  or  vessels)  below  that  sur- 
face. The  characteristic  local  evidences  of  syphilitic 
infection  may,  however,  be  modified  and  more  or  less 
completely  obscured  by  accidental  lesions,  such  as  her- 
pes, resulting  from  contact  with  vicious  vaginal   and 


SYPHILIS  AND  THE   GENITO-URINARY  DISEASES.     65 

uterine  secretions,  or  other  causes,  or  by  contact  of  the 
lesion  of  syphilitic  inoculation  with  the  virus  of  chan- 
croid. 

Such  lesions  pursue  their  course  uninfluenced  by  the 
syphilitic  cell-proliferation  previously  inaugurated,  and 
may  thus  obscure  diagnosis  until  evidences  of  constitu- 
tional infection  are  manifest. 

Hence,  wherever  the  possibility  of  a  syphilitic  infec- 
tion is  present,  any  breach  of  tissue,  whether  a  simple 
abrasion  or  fracture  of  mucous  membrane  or  integu- 
ment, or  any  vesicle  or  pustule,  whether  from  general 
or  venereal  causes,  whether  healing  as  if  simple  or  pur- 
suing the  characteristic  course  of  the  chancroid,  then 
in  such  case,  opinions  in  regard  to  \h^  presence  or  absence 
of  the  contagiiiM  of  syphilis  must  be  reserved  until 
such  time,  from  the  date  of  latest  exposure,  as  will  equal 
t lie  longest  period  knozvn  to  obtain  between  inoculation  and 
syphilitic  infection,  as  indicated  by  induration  of  the'local 
lesion  and  enlargement  and  induration  of  the  adjacent 
lymphatic  glands.     This  is  not  less  than  forty  days. 


66  PRACTICAL   CLINICAL   LESSONS   ON 


LESSON  VIIL 

Treatment  of  the  Initial  Lesion  of  Syphilis  by  Excision — Description  of 
Operation  and  Subsequent  Care — Constitutional  Treatment  also  Es- 
sential^Local  Measures  where  Excision  is  not  Applicable — Relief  from 
Accumulated  Cell  Material  causing  the  Chancre  occurs  only  through 
Fatty  Metamorphosis — Mercury  the  most  Efficient  Agent  both  Locally 
and  Internally — Forms,  Doses,  and  Modes  of  Administrations — Treat- 
ment by  Inunction — General  Care — Treatment  of  Modifications — i. 
Mucoid  Form — 2.  Inflamed  or  Suppurating — 3.  Gangrenous — Treat- 
ment of  Concealed  Initial  Lesions — Treatment  to  be  Continued  after  the 
Cure  of  the  Initial  Lesion — Increase  or  Diminution  of  the  Induration  a 
Barometer  for  Treatment — Enlargement  and  Induration  of  Lymphatic 
Glands  nearest  to  Initial  Lesion  the  First  Positive  Evidence  of  Progress 
of  the  Infection. 


TREATMENT   OF   THE   INITIAL  LESION  OF  SYPHILIS. 

First,  by  Excision.  Whenever  a  well-determined  initial 
lesion  is  situated  in  loose  tissue  (integument  or  folds  of 
prepuce  in  males,  or  of  the  vulva  in  females)  the  earlier 
removal  by  excision  is  accomplished  the  better.  Not 
with  the  expectation  of  preventmg  constitutional  infec- 
tion (which,  as  a  rule,  is  inevitable  before  the  local  lesion 
is  discovered),  but  as  far  as  possible  to  remove  a  focus 
of  dissemination  for  diseased  elements,  and  to  diminish 
the  danger  of  conveying  disease  to  others. 

The  infective  neoplasm,  whether  under  sound  skin  or 
appearing  in  any  one  of  the  forms  or  modifications 
previously  described  (except  the  inflamed  or  suppurat- 
ing), should  be  removed  entii-e.  The  resulting  wound 
heals,  as  a  rule,  by  first  intention.  Even  when  the  in- 
duration is  large,  little  if  any  deformity  remains  after 
cicatrization.  Practically  the  indurated  tissue  is  a  for- 
eign body,  and  its  thorough  removal  requires  the  sacri- 
fice of  but  little  of  the  surrounding  healthy  structure. 
Favorably  situated  open  initial  lesions  of  long  standing 
may  be  promptly  cured  in  this  way. 

For  the  performance  of  this  operation  first  cleanse 
the  parts  thoroughly  by  gentle  bathing  in  warm  water. 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.      6'] 

In  all  Open  lesions  apply  a  solution  of  carbolic  acid  of  a 
strength  of  one  part  of  the  acid  to  forty  parts  of  water, 
after  which  raise  the  mass  of  induration  between  the 
forefinger  and  thumb,  and  encircle  it  firmly  at  the  base 
with  a  bit  of  fine  silver  or  malleable  iron  wire.  The  in- 
durated part  may  be  separated  from  the  normal  tissue 
in  the  same  way  by  compression  between  the  arms  of  a 
bent  probe,  being  careful  to  include  the  entire  indura- 
tion. 

Now  with  a  narrow,  sharp-pointed  bistoury  pierce 
the  tissues  at  the  centre  beneath  the  compressing  wire 
probe,  and  cut  well  under  and  out,  including  all  the 
indurated  and  a  little  of  the  sound  tissue  of  that  side. 
This  effected,  from  the  place  of  beginning,  cut  out  in 
the  same  way  on  the  opposite  side.  Be  assured  by 
careful  examination  that  every  portion  of  the  neoplasm 
is  removed,  then  introduce  interrupted  sutures  of  silk 
or  silver  wire  at  intervals  of  a  quarter  of  an  inch  or  less. 

The  patient  should  be  kept  in  the  recumbent  position, 
the  parts  constantly  wet  with  carbolated  water,  until 
the  third  day,  when  on  removal  of  the  sutures  union  by 
first  intention  will,  as  a  rule,  be  found  to  have  taken 
place. 

The  resulting  cicatrix  may  indurate,  to  a  greater  or 
less  degree,  but  rarely,  if  ever,  to  the  extent  of  inducing 
a  solution  of  continuity. 

In  no  case  does  this  procedure  lessen  the  necessity 
for  Constitutional  Treatment.  The  indurated  papule, 
when  so  located  that  excision  is  unadvisable  (as  on  the 
glans penis,  or  involving  the  tissues  of  the  corpora),  may 
be  subjected  to  applications  of  the  oleate  of  mercury 
(six  per  cent  solution),  or  any  correspondingly  mild 
mercurial  ointment.  When  the  mucous  membrane  or 
cuticle  covering  the  finduration  is  abraded,  or  at  any 
stage  of  simple  necrobiosis,  dusting  the  surface  with  dry 
calomel  and  protecting  it  with  a  thin  layer  of  dry  lint 
is  then  serviceable.  Calomel,  in  combination  with  lime- 
water,  in  the  proportion  of  a  drachm  to  the  pint  {lotio 
nigra),  or  bichloride  of  mercury,  half  a  drachm  to  the 
pint  of  lime-water  (lotio  flava),  arc  both  much  esteemed 
as  applications  to  the  open  initial  lesion.     The  tissue 


68  PRACTICAL   CLINICAL   LESSONS   OM 

metamorphosis  and  absorption,  which  are  requisite  for 
the  removal  of  the  syphilitic  neoplasm,  are  most  readily 
induced  by  the  internal  administration  of  some  one  of 
the  various  mercurial  preparations.  In  all  forms  of  the 
initial  lesion  the  chief  obstacle  to  resolution  or  healing 
is  the  mechanical  interference  to  nutrition  occasioned 
by  accumulated  cell-growth.  Its  removal  must  occur 
through  the  process  known  as  fatty  degeneration.  The 
most  active  and  reliable  agent  in  effecting  this  and  in 
promoting  the  necessary  subsequent  absorption  and 
elimination,  is  mercury;  hence  the  internal  administra- 
tion of  some  mercurial  preparation  is  essential  in  all 
well-determined  initial  lesions.  The  proto-iodide  (so- 
called  green  iodzde)  of  mercury,  in  pill,  one  quarter  grain 
to  one  grain,  three  times  a  day.  The  biniodide  in  one 
thirtieth  to  one  twelfth.  The  bichloride  in  doses  of 
from  one  thirtieth  to  one  tw^elfth  of  a  grain.  The  mass, 
hydrargyrum,  from  two  to  four  grains,  and  may  be 
judiciously  combined  with  iron.  A  favorite  formula, 
and  one  which  I  usually  prescribe,  consists  of  two  grains 
mass,  hvdrarg.  with  one  of  the  exsiccated  sulphate  of 
iron.  This  ma}^  be  made  into  a  pill,  and  if  intestinal 
irritation  ensue  one  fourth  grain  of  the  watery  extract 
of  opium  may  be  added.  This  pill  was  first  suggested 
to  me  by  the  late  Dr.  Bumstead,  and  is  sometimes 
i^nown  as  pil.  Dzio  or  Duplex.  Any  of  these  forms  of 
mercury  may  be  administered  (in  suitable  vehicles),  in 
the  dose  deemed  judicious  for  the  presenting  case,  three 
times  a  day  (increasing  the  dose  if  necessary  to  the 
limit  as  above  indicated),  until  the  constitutional  influ- 
ence of  the  drug  is  manifested  by  a  spongy  and  sensitive 
condition  of  the  gums  or  a  slight  mercurial  odor  in  the 
breath. 

In  introduction  of  mercury  into  the  system  through 
inunction  of  the  mild  ointment  of  mercury,  where  this 
drug  is  not  well  borne  by  the  digestive  apparatus — a 
dram  rubbed  in  morning  and  evening — changing  locality 
each  apphcation — thus,  in  right  axilla  in  morning,  left 
at  night;  then  under  left  knee,  then  right;  then  right 
axilla  again,  and  so  on,  until  the  desired  effect  on  gums  is 


SYPHILIS   AND   THE    GENITO-URINARY   DISEASES.      69 

produced;  then  reduce  amount  so  as  to  keep  just  below 
this  point. 

The  mercurial  impression  should  be  maintained  as 
nearly  as  possible  at  this  point  luitil  complete  absorption 
of  the  local  neoplasm  has  been  effected,  its  further  em- 
ployment will  be  considered  in  the  Lessons  on  Treat- 
ment of  General  or  Constitutional  Syphilis. 

Cleanliness,  freedom  from  friction  and  irritation  from 
all  other  causes,  simple  diet,  and  abstinence  from  alco- 
holic stimuli,  are  necessary  to  the  most  favorable  results 
in  treatment  of  the  Initial  Lesion  as  well  as  all  other 
forms  of  syphilis. 

In  regard  to  the  modifications  of  the  initial  lesion  of 
syphilis  :  The  mucoid  form  requires,  in  addition  to  the 
constitutional  treatment  previously  described,  the  appli- 
cation of  the  solid  argentum  nitratis  (or  some  other 
caustic),  sufficient  ojily  to  destroy  and  subsequently  to 
repress  the  exuberant  granulations.  The  inflamed  or 
suppurating  initial  lesion,  requires  rest  and  opiate  or 
sedative  dressing,  as  the  lotio  plumbi  et  opii,  in  the  pro- 
portion of  five  grains  each  to  the  ounce  of  water  ;  or 
the  powdered  iodoform,  simple,  or  with  an  equal  part  of 
tannic  acid,  which  seems  to  deodorize  in  some  degree, 
and  possibly  increases  the  efficiency  of  the  iodoform. 
In  the  gangrenous  form  the  powdered  iodoform  is  effi- 
cient as  an  antiseptic. 

Poultices  of  powdered  charcoal  are  also  of  value,  but 
the  internal  administration  of  mercury  must  not  be 
neglected  while  the  gangrenous  action  is  limited  to  the  in- 
duration. Passing  beyond  this  point,  prompt  and  thor- 
ough cauterization  under  ether,  with  the  fuming  nitric 
acid  or  the  galvano  or  the  gas  cautery,  should  be  done 
so  as  completelv  to  destroy  the  tissues  involved  in  the 
destructive  action.  Opium  is  of  great  value  in  subdu- 
ing pain  in  these  cases,  as  well  as  on  account  of  its  bra- 
cing effect  on  the  nervous  system.  Occurring  in  debili- 
tated or  highly  scrofulous  subjects,  as  is  usually  the 
case,  attention  should  be  given  to  general  support,  by 
generous  diet,  quinine,  and  iron.  The  potassio-tartrate 
of  irouy  in  fifteen-  to  twenty-grain  doses  every  three  or 


70  PRACTICAL  CLINICAL  LESSONS   ON 

four  hours  (as  recommended  by  Ricord),  seems  to  exert 
a  specific  influence  over  gangrenous  conditions. 

It  must  not  be  forgotten  that  healing  and  apparent 
cure  of  the  initial  lesion  does  not  mean  cure  of  syphilis. 
After  disappearance,  more  or  less  complete,  the  indura- 
tion may  return.  Not  unfrequently  it  may  be  observed 
to  increase  or  diminish  in  apparent  sympathy  with  the 
progress  or  abatement  of  the  constitutional  disease. 
From  this  fact  the  local  induration  has  come  to  be  con- 
sidered by  some  as  a  reliable  barometer,  by  which  the 
effect  of  general  treatment  may  be  appreciated.  The 
duration  of  the  initial  lesion  varies  greatly  in  different 
cases,  sometimes  disappearing  within  a  few  weeks,  and 
with  it  every  trace  of  induration ;  at  others  it  continues 
as  an  induration,  more  or  less  distinctly  marked, 
throughout  the  active  stage  of  the  constitutional  infec- 
tion. Enlargement  and  induration  of  the  lymphatic 
glands,  nearest  in  connection  with  the  initial  lesion, 
constitute  the  first  positive  evidence  of  the  progress  of 
constitutional  infection. 

Concealed  initial  lesions  (as  within  the  meatus  uri- 
narius  or  the  anus)  may  be  treated  with  bougies  or 
suppositories  medicated  with  opium,  salicylic  acid,  or 
iodoform. 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.      7 1 


LESSON  IX. 

On  the  Early  Manifestations  of  Syphilis — The  Organism  not  Infected  at 
once,  but  by  a  Gradual  Process,  through  Normal  Physiological  Chan- 
nels— No  Constitutional  Evidence  of  the  Disease  at  any  Point  until  at 
least  Thirty  or  Forty  Days  after  Inoculation — Roseola  of  Syphilis — 
Clinical  Case — Roseola  of  Syphilis  shown  to  be  the  Result  of  Sympa- 
thetic Nerve  Disturbance  like  Simple  Roseolas,  and  not  Caused  by 
the  Local  Accumulation  of  Syphilitic  Material — Pigmentation  Due  to 
Exudation  of  the  Coloring  Matter  of  the  Blood  and  not  to  a  Specific 
Material — Clinical  Case  Illustrating  the  Papular  Eruption  of  Syphilis 
and  its  Comcomitants — Supernumerary  Epitrochlear  Gland — Mucous 
Patches  Simulating  Diphtheria — The  Secretions  of  all  Lesions  of  this 
Stage  of  Syphilis  Inoculable — Note  in  Regard  to  the  Contagion  of  Syphi- 
lis— Importance  of  Care  to  Prevent  the  Same — The  Necessity  of  an 
Artificial  Port  of  Entry  a  Great  Security  against  the  Acquirement  of  the 
Disease — Illustrative  Cases, 


EARLY   CONSTITUTIONAL   FORMS   OF   SYPHILIS. 

The  cases  to  which  your  attention  is  now  invited  are 
in  illustration  of  the  acute  stages  of  syphilis,  and  these 
include  all  the  manifestations  of  the  disease  during- 
which  a  contagious  element  pertains  to  it.  The  first 
manifestation,  the  "  initial  lesion'  in  its  varied  forms,  has 
already  been  considered.  The  adjacent  gland  enlarge- 
ments, resulting  from  the  same  processes  of  cell  prolife- 
ration and  localized  accumulation,  have  been  seen  to  be 
an  inseparable  adjunct  in  every  case,  but  they  have 
been  present  without  the  least  evidence  of  constitu- 
tional disturbance.  No  sensation  of  the  patient,  nor 
any  recognized  physical  sign,  suggests  anything  more 
than  a  local  disease.  Notwithstanding  the  claim  of  cer- 
tain authorities  that  syphilis  is  a  constitutional  disease 
at  the  moment  of  inoculation,  and  that,  as  Billroth  puts 
it,  the  "organism  is  infected  at  once,""^  all  the  scientific 
research  yet  made,  goes  to  prove  that  the  disease  pro- 
gresses by  individual  infection  of  germinal  cells,  from 

*  Billroth's  Surgical  Pathology.     Am.  ed,,  p.  386, 


72  PRACTICAL  CLINICAL  LESSONS   ON 

the  point  of  inoculation,  along  the  lymphatic  channels, 
one  of  the  chief  offices  of  which,  is  to  carry  germinal 
material  from  the  tissues  into  the  general  blood  cur- 
rent. That  their  progress  is  slow  and  is  obstructed 
by  the  lymphatic  glands  is  made  manifest,  in  every  case, 
by  the  enlargement  of  all  those  immediately  interposed 
between  the  point  of  inoculation  and  the  great  lym- 
phatic reservoir,  the  receptaculum  cliyli,  and  by  the  fact 
that,  until  at  least  thirty  or  forty  days  after  the  inocu- 
lation, there  is  absolutely  no  evidence  of  the  disease 
having  reached  the  general  blood  current.  In  other 
words,  it  may  be  said,  that,  up  to  such  time,  the  infection 
is  confined  to  the  locality  of  the  inoculated  point  and 
the  glands  in  immediate  connection  with  it,  and  cannot 
yet  be  said  to  be  a  constitutional  disease.  At  about  the 
sixth  week,  however,  an  eruption  presents,  as  the  first 
evidence  that  the  disease  has  found  access  to  the  system 
at  large.  This  is  well  shown  in  the  patient  now  before 
you.  He  has  a  history  of  suspicious  venereal  connec- 
tions— of  one  in  particular  about  two  months  since. 
He  accidentally  noticed  a  small  abrasion  on  the  inside 
of  his  prepuce,  near  the  "  bridle"  on  the  left  side,  which 
bothered  him  for  several  weeks,  but  was  never  of  suf- 
ficient account  to  consult  a  surgeon  about,  and  finally 
healed.  Yesterday,  after  getting  quite  heated  in  a  run- 
ning match,  his  face  became  spotted  with  red  blotches, 
and,  on  going  to  bed,  he  found  his  body  more  or  less 
covered  with  them.  Here  you  have  a  fine  specimen  of 
the  roseola  of  syphilis.  Its  history  and  advent  are  char- 
acteristic. There  is  a  distinct  thickening  easily  felt  at 
the  point  referred  to  as  the  site  of  the  abrasion.  It  is 
not  as  characteristic  as  in  many  cases  you  have  seen, 
but  is  sufficient,  when  taken  in  connection  with  the 
history,  the  distinctly  enlarged  inguinal  glands,  and  the 
roseola,  to  characterize  the  initial  lesion  of  syphilis. 

The  glands  of  the  cervical  region  are  also  enlarged, 
so  that  we  may  accept  the  case  as  a  classical  one  of 
early  constitutional  syphilis,  which  I  have  been  accus- 
tomed to  designate,  on  account  of  the  tendency  to 
localized  accumulation  in  the  glands  at  a  distance  from 
the  point  of  inoculation,  and  in  the  skin  at  a  later  period, 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES,      y^ 

as  tke  period  of  general  infection  and  localized  cell  accumu- 
lation.'^ 

In  its  general  appearance  this  exanthem  is  not  un> 
like  a  slight  eruption  of  measles.  Pressure  with  the 
finger  in  the  syphilitic  roseola  causes  the  color  to  dis- 
appear completely  when  the  eruption  is  recent,  as  in 
the  present  instance,  but  when  it  has  existed  for  some 
weeks  a  brownish  or  copper-colored  stain  is  left.  The 
longer  the  eruption  remains,  the  more  likely  it  is  to- 
leave  its  characteristic  trace,  namely,  a  coppery  stain,, 
unaffected  by  pressure.  The  color  of  this  stain  here,, 
as  well  as  in  other  syphilitic  eruptions,  is  usually  con> 
sidered  valuable  as  a  diagnostic  mark  of  syphilis.  With 
this  exception,  however,  it  is  not  materially  different 
from  an  idiopathic  roseola.  Like  the  latter,  it  appears 
suddenly,  often  during  or  following  any  exercise  which 
gives  a  violent  impetus  to  the  circulation  of  the  blood,, 
such  as  rowing,  dancing,  or  running. 

Pain  or  other  premonitory  symptom  is  not  necessarily 
associated  with  it.  Sometimes  it  is  slight,  consisting 
only  of  a  few  pale  spots;  while  again  it  is  profuse  and 
highly  colored,  and  occasionally  slightly  elevated.  But 
it  never  develops  into  any  other  form  of  lesion.  Beyond 
a  reddish  blotch,  it  is  never  more  than  a  copper-colored 
stain ;  and  even  this  stain,  the  only  really  salient  point 
of  difference  between  simple  roseola  and  that  which  is 
thus  seen  to  be  associated  with  the  advent  of  constitu- 
tional syphilis,  will  be  shown  to  result  from  simple 
causes.  It  is  true  that  this  eruption  is  popularly 
accepted  as  syphilitic,  in  the  sense  that  it  is  caused  by 
the  local  presence  of  syphilitic  material,  and  is  to  be 
gotten  rid  of  through  the  same  means  by  which  the 
specific  cell  accumulations  (forming  papules  in  the  skin 
and  mucous  membranes)  at  a  later  stage  of  the  disease 
are  eliminated.  I  believe,  however,  that  this  can  be 
shown  to  be  an  error,  and  that  this  roseola,  like  all  the 
other  roseolas,  is  the  result  of  a  purely  functional  dis- 
turbance.    Baumler   says   of   it:  ''In    ever}^   syphilitic 

*  For  further  information  as  to  the  causes  of  the  "  Roseola  of  Syphilis," 
see  Otis  on  the  Physiolocjy,  Pathology,  and  Treatment  of  Syphilis,  p.  17. 
New  York:  Putnam.     i88r. 


74  PRACTICAL   CLINICAL  LESSONS   ON 

efflorescence  there  is  a  circumscribed  dilatation  of  blood- 
vessels, together  with  a  certain  amount  of  exudation  of 
white-blood  cells  into  the  sheaths  of  the  vessels  merely, 
and  into  the  surrounding  tissue.  The  greater  the  de- 
gree of  stasis  the  more  abundant  will  the  exudation  of 
red  corpuscles  be ;  and  it  is  the  alteration  of  the  coloring 
matter  i7i  these  red  globules  which  imparts  to  the  color  of 
the  sypJiilides,  after  they  have  remained  for  some  time,  their 
yellowish  or  brownish  shades.  These  shades  are  more 
distinct  in  proportion  as  the  congestion  of  the  vessels 
thereby  occasioned  recedes,  and  they  are  more  pro- 
nounced the  longer  the  stasis  has  continued.  In  the 
same  way  any  efflorescence  or  its  imamediate  vicinity, 
or  scars  following  ulcers  on  the  lower  extremities,  not 
due  to  syphilis,  may  assume  this  color.  Long-continued 
dilatation  of  capillaries  and  stasis  of  the  blood  are  all 
that  is  necessary  to  produce  pigmentation." 

Case  11.  Here  is  another  case  presenting  the  charac- 
teristic developments  of  syphilis  at  a  somewhat  later 
period,  and  affords  us  an  excellent  opportunity  of  a 
further  study  of  its  leading  features.  The  initial  lesion 
is  said  to  have  occurred  four  months  ago,  and  one  month 
after  the  suspicious  connection.  It  healed  in  a  couple  of 
weeks.  During  its  presence  the  patient  says  it  looked 
hke  a  simple  sore,  but  there  is  still  here  a  little  knot  of 
induration,  situated  in  the  loose  tissue  of  the  prepuce, 
indicating  the  character  as  well  as  the  locality  of  the 
lesion.  We  find  also  Avell-marked  enlargement  of  the 
lymphatic  glands  of  the  groins,  and  particularly  below 
Poupart's  ligament,  on  both  sides,  which  latter  is  quite 
unusual  at  so  early  a  period  of  the  infection.  You 
also  observe  very  plainly  an  eruption  on  the  forehead. 
It  is  papular  in  character,  and  is  characteristic  of  the 
secondary  eruption  of  syphilis,  the  first  eruption  being 
a  roseola,  which  usually  comes  on  at  a  period  varying 
from  six  weeks  to  two  months  after  the  appearance 
of  the  initial  lesion.  Then,  after  another  interval  of 
about  the  same  length  of  time,  we  get  the  second  erup- 
tion, which  is  papular  in  character ;  the  first — the  roseola 
— being  macular,  and  occasionally  slightly  elevated. 
The  second  eruption  has  been  described  by  authors  as 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.      75 

of  a  raw-ham  color  or  a  coppery  hue.  It  is  rosy  in 
color  when  it  first  makes  its  appearance,  but  grows 
darker  and  darker,  until  finally  the  papule  passes  away, 
leaving  a  distinct  reddish  or  copper-colored  stain.  You 
will  observe  in  this  patient  that  the  eruption  is  very 
prominent  and  wide-spread  over  the  back.  Some  of 
the  papules  are  surrounded  by  a  little  exfoliated  epi- 
dermis, which  is  known  as  the  "  collarette  of  Biett," 
and  is  considered  characteristic  of  a  syphilitic  lesion 
by  some  writers.  It  is  simply  an  exfohation  of  the 
epidermis  of  the  surface  of  the  papule,  seen  most  dis- 
tinctly at  its  base,  and  is  dependent  upon  modified 
nutrition,  caused  by  infiltration  of  the  papules  with  cells. 
These  interfere  with  the  vascular  supply  of  the  part, 
and  we  get  the  exfoliation  here  exactly  in  the  same  way 
that  we  get  it  at  the  point  of  initial  lesion — from  accumu- 
lation and  concentration  of  cells  in  that  locality.  When 
this  exfohation  is  present  on  a  papule,  it  affords  an  ad- 
ditional proof  of  the  syphilitic  character  of  the  trouble. 
You  will,  however,  see  cases  of  psoriasis  where  the 
scales  have  been  brushed  off,  which  so  nearly  simulate 
the  syphilitic  papular  eruption  that  it  is  impossible 
to  distinguish  between  them ;  and  without  other  aid 
we  are  often  obhged  to  wait  further  developments  in 
order  to  make  the  diagnosis.  Fortunately,  however, 
for  the  diagnosis,  but  unfortunately  for  the  patient,  we 
nearly  always  have,  at  the  time  of  the  occurrence  of 
this  papular  eruption,  other  lesions  which  aid  us  in 
making  the  diagnosis.  The  glandular  enlargements  in 
the  groins,  of  the  neck,  and  also  in  the  epitrochlean 
spaces — sometimes  one,  sometimes  all — ought  to  be 
well  marked  by  this  time.  You  will  observe  here  on 
the  neck  a  gland  which  can  be  seen  at  quite  a  distance 
— it  is  so  much  enlarged.  There  is  a  group  of  enlarged 
and  indurated  glands  just  behind  the  sterno-cleido-mas- 
toid  muscle,  and  another  farther  back  on  either  side. 
Here  in  the  right  epitrochlean  space  there  is  an  en- 
larged gland  about  the  size  of  a  large  pea,  and  what  I 
do  not  remember  to  have  ever  found  before,  viz.,  an- 
other gland  about  two  inches  higher  up,  only  a  trifle 
smaller  than  the  first.     Quite   often  the  epitrochlean 


76  PRACTICAL  CLINICAL  LESSONS  ON 

gland,  instead  of  being  in  the  little  space  above  the  in- 
ternal  condyle  of  the  humerus,  is  found  an  inch  or  two 
or  three  inches  higher  up,  between  the  borders  of  the 
biceps  and  the  triceps;  but  a  supernumerary  gland,  as 
in  the  present  instance,  is  very  rare.  By  this  tune  also 
papules  occur  in  the  mucous  membrane,  and  these  are 
especially  characteristic,  there  being  nothing  else  which 
resembles  them,  unless  possibly  in  psoriasis.  When 
syphilitic  papules  occur  in  mucous  membrane  they 
usually  soon  become  eroded  and  covered  with  a  diph- 
theritic pellicle  to  greater  or  less  extent. 

Mucous  patches — really  papules — in  the  mouth  are 
characteristic  of  syphilis  in  its  acute  stage,  and  are 
present  in  a  marked  degree  in  this  case.  The  mouth  and 
the  tongue  are  literally  covered  with  them  to  an  extent 
which  you  rarely  see.  These  papules,  which  appear  on 
the  tongue,  throat,  and  mouth,  are  superficial,  and  so 
fiat  that  they  are  scarcely  if  at  all  raised  above  the  sur- 
rounding surface  or  spread  over  an  area  varying  from 
the  size  of  a  pea  to  that  of  half  a  dollar  or  larger,  hav- 
ing often  a  gray  or  pearl  colored  diphtheritic  edge  which 
occasionally  festoons  the  edge  of  the  soft  palate,  form- 
ing a  very  characteristic  and  unmistakable  mark  of 
syphilis.  Some  time  ago  I  was  called  to  see  a  man 
who  \vas  supposed  to  be  suffering  from  diphtheria.  I 
found  him  surrounded  by  his  family,  who  were  in  great 
solicitude  about  him.  On  looking  into  his  throat  I  saw 
this  characteristic  festooning  of  the  palate,  and  did  not 
hesitate  a  moment  in  making  up  my  mind  that  the 
trouble  was  syphilitic.  Soon  having  an  opportunity  to 
speak  to  the  young  man  alone,  I  discovered  that  he  had 
syphilis,  although  he  had  not  before  been  aware  of  it. 
The  mucous  patch  is  also  liable  to  occur  between  the 
toes  or  any  place  where  there  is  habitual  moisture. 
Just  at  the  verge  of  the  anus  is  a  favorite  seat  for  it ; 
and  knowing  this  fact,  examination  of  this  locality  will 
often  help  you  out  in  the  diagnosis  of  an  obscure  case. 
The  mucous  papule,  from  its  prominence  when  on  the 
skin  or  semi^mucous  membrane  about  the  anus,  is  usu- 
ally called  a  mucous  tubercle,  and  is  quite  characteris- 
tic in  this  patient,  as  you  see, 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.      "]*] 

You  should  bear  in  mind  that  the  secretions  of  all 
lesions  during  this  stage  of  the  disease  are  inoculable, 
and  one  suffering  from  it  may  communicate  the  disease 
from  the  secretion  of  any  open  lesion  upon  the  body 
or  on  the  mucous  membranes."^     You  will  understand, 

*  The  active  period  of  syphilis,  thus  shown  to  be  marked  by  exces- 
sive localized  cell  proliferation,  is  equally  characterized  by  the  contagious 
property  attaching  to  cells  thus  generated.  Inoculation  of  the  blood,  and 
of  the  secretion  of  all  open  lesions  during  the  active  period  of  syphilis, 
-has  been  found  capable  of  communicating  syphilis  promptly  to  healthy 
persons. 

The  physiolo  ical  secretions — milk,  saliva,  urine,  perspiration,  tears, 
and  spermatic  fluid — have  not  bee^i proven  to  be  agents  of  syphiliiicinfectioji. 
Where  apparently  so,  in  many  cases,  syphilitic  lesions  of  the  mouth  or 
breast  have  been  found  to  account  for  the  seeming  inoculability  of  the 
saliva  or  of  the  milk.  Repeated  experiments*  have  been  made  by  inocu- 
lation of  the  spermatic  fluid  of  a  person  proven  to  be  in  the  active  stage 
of  syphilis  upon  healthy  persons,  with  absolutely  negative  results.  In 
this  we  find  confirmation  of  our  position  that  the  contagious  property  of 
syphilis  is  not  an  entity,  an  independent  virus,  pervading  all  the  tissues 
and  fluids  of  the  organism,  but  that  it  is  confined  to  the  white-blood  or 
tissue-building  cells,  and  in  this  view  we  readily  see  how  the  physiologi- 
cal secretions  above  mentioned,  which  do  not  contain  them,  are  found 
also  to  be  free  from  the  contagious  property  of  syphilis. 

Thus  far  the  only  distinguishing  feature  which  has  been  recognized 
between  normal  embryonal  cells  and  cells  which  make  up  the  accumula- 
tions characteristic  of  the  active  stage  of  syphilis  is  the  possession  by 
the  latter  of  the  contagious  property ;  in  other  words,  a  co7itagiu?n — the 
power  of  setting  up  in  other  cells,  through  simple  contact,  the  same  dis- 
position to  rapid  proliferation  which  the  so-called  syphilitic  cells  are 
known  to  possess.  The  direct  result  of  this  hasty  proliferation,  as  far 
as  we  have  yet  been  able  to  discover,  is  not  a  destructive  actioji.  It  is 
simply  and  only  what  we  should  naturally  expect  from  hastily  generated 
normal  material  in  excess  of  the  necessities  of  growth  and  repair.  In 
re  resentative,  uncomplicated  cases  it  remains  for  a  time  obstructing  the 
tissues  by  its  presence,  and  then  through  purely  normal  processes,  often 
of  necessity  set  into  operation  by  crowding  of  the  newly  formed  cells, 
prolonged  pressure,  and  consequent  innutrition,  and  also  from  general 
causes  it  undergoes  fatty  degeneration,  and  is  in  this  way  finally  elimi- 
nated from  the  affected  organism. f 

Baumler  virtually  supports  this  view:]:  when  he  says  of  the  active  stage 
of  syphilis,  "  If  there  are  only  a  few  local  deposits,  the  elimination  of  the 
virus  may  be  so  much  in  excess  of  its  production  that  the  organism  is 
gradually  freed  from  it.  This  takes  place  in  the  majority  of  cases,  and  at 
the  expiration  of  eighteen  months  or  two  years  the  infection  is  entirely  ex- 
hausted.^' 

*  Dr.  Mireur,  of  Marseilles.  Annales  de  Dermatologie  et  de  Syphilographie,  No.  6, 
tome  viii.,  1877. 

t  A  fatty  metamorphosis,  entirely  like  that  which  occurs  pathologically,  occurs  la  the 
normal  condition  of  the  organism.     Wagner,  p.  305. 

%'P.  247  of  Ziemssen's  Cyclopaedia,  Am.  ed.,  vol.  iii. 


78  PRACTICAL  CLINICAL  LESSONS   ON 

therefore,  the  importance  of  warning  the  patient  having 
such  lesion  of  the  danger  of  communicating  the  disease 
to  others  by  contact.  A  pencil,  a  pipe,  a  spoon,  a  knife, 
or  other  article  introduced  into  the  mouth  where  mu- 
cous patches  are  present,  some  of  this  secretion  con- 
tained in  the  saliva  drying  upon  it,  and  afterward 
coming  in  contact  with  an  abrasion  of  the  lips  of  an- 
other person,  will  communicate  syphilis  to  that  person 
as  positively  and  certainly  as  would  a  syphilitic  vene- 
real connection.  From  this  you  may  see  that  syphihs 
is  not  necessarily  a  venereal  disease,  but  any  one  ex- 
posed in  the  ways  above  referred  to  is  liable  to  receive 
it,  in  which  event  it  will  follow  the  same  course  as  if 
acquired  by  venereal  connection.  The  great  security 
which  we  all  have  against  the  accidental  acquirement 
of  syphilis  is,  that  it  requires  an  artificial  port  of  en- 
trance— a  fracture  of  the  skin  or  of  the  mucous  mem- 
Mr.  Hutchinson,  of  London,  in  speaking  of  the  contagious  property 
which  attaches  to  the  emasculated  white-blood  cell,  which  we  call  pus, 
says,  ^' All  living  pus  is  contagious.  .  .  .  I  mean,"  he  further  says,  "that 
all  pus  cells  possess  the  power  of  setting  up,  when  transferred  to  another 
home,  if  that  home  be  a  suitable  one,  a  kind  of  inflammatory  action 
similar  to  that  from  whence  they  themselves  had  originated."  This, 
we  know,  results  in  the  almost  immediate  death  of  cells  in  localities  so 
contaminated.  In  the  case  of  the  germinal  cells  contaminated  by  con- 
tact with  the  syphilitic  cells,  however,  this  results  only  in  a  hasty  genesis 
of  cells,  a  too  rapid  production,  which  prevents  their  highest  develop- 
ment; they  fall  by  the  way,  are  heaped  up,  undergo  fatty  degeneration, 
and  are  or  may  be  eliminated.  Nor  is  it  alone  in  diseased  cells  that  a 
contagious  property  is  claimed  to  reside.  Rindfleisch,  an  eminent  Ger- 
man authority,  in  speaking  of  embryonal  cells  coming  up  from  the  tissue 
juices  for  the  regeneration  of  mucous  membranes,  says  of  such  cells  that 
'''they  become  epithelial  cells  only  by  coining  into  coiitact  with  such.  We 
must  believe,"  he  continues,  "  in  a  kind  of  epithelial  infection."  This, 
he  says  also,  "  must  of  course  just  as  well  obtain  when  embryonal  forma- 
tive cells  approach  an  existing  epithelial  stratum,  as  when,  conversely, 
epithelial  elements  approach  embryonal  formative  cells."  If  this  be 
true,  it  at  once  becomes  evident  that  the  contagious  property  is  not  of 
necessity  a  virus ;  and  it  must  I  think  be  suggested,  in  this  view  of  the 
matter,  as  equally  evident  that  the  so-called  virus  of  syphilis  is  simply  a 
manifestation  of  that  property  or  personal  influence  inherent  in  all  cells, 
whether  healthy  or  degraded,  and  which  is  as  subtle  and  intangible,  as 
incapable  of  material  demonstration,  as  the  influence  which  one  mind 
exerts  over  another.  Is  it  not  then  possible  that  the  mischief  which 
syphilis  does  is  rather  the  result  of  an  interference  with  the  normal  pro- 
cesses, through  hasty  development  brought  about  by  this  influence,  than 
of  the  action  of  a  specific  virus  ? 


SYPHILIS  AND  THE   GENlTO-URlNARY  DISEASES.      7g 

bfane  for  its  inoculation.  Otherwise,  sooner  or  later,  we 
should  all  be  likely  to  have  it,  for  we  could  not  come  in 
contact  with  people  who  have  syphilis  without  danger 
of  getting  it  at  every  turn.  But  fortunately  it  requires 
an  abrasion,  an  open  port  of  entry.  It  is  rarely  through 
the  ordinary  affectionate  relations  between  children  and 
parents,  brother  and  sisters,  that  communication  of  the 
disease  takes  place.  If,  however,  an  abrasion  exist  upon 
the  lips  of  both  parties  the  disease  may  be  communi- 
cated from  the  one  to  the  other  by  a  kiss.  I  have  often 
known  this  to  occur  in  the  venereal  kiss,  but  never  by 
the  ordinary  kiss  of  courtesy  and  family  affection.  But 
the  liability  to  communicate  the  poison  to  an  innocent 
person  should  be  borne  in  mind  by  every  one  passing 
through  the  acute  stage  of  syphilis.  We  must  also  bear 
in  mind  the  fact  that  the  disease  may  be  transferred 
from  a  syphilitic  to  an  innocent  person,  by  the  physi- 
cian, by  the  use  of  the  spatula,  carelessly  laying  it  down 
after  examining  a  syphilitic  mouth,  allowing  the  secre- 
tions to  dry  upon  it,  then  introducing  it  into  the  mouth 
of  another  patient  before  properly  cleansing  it.  This 
is  especially  liable  to  occur  if  the  second  patient  be  a 
child,  as  by  its  restlessness  during  the  examination,  a 
lesion  of  the  mucous  membrane  of  the  mouth  may  be 
made  by  the  instrument.  All  instruments  in  use  about 
the  mouth,  throat,  or  teeth  should  be  carefully  cleansed 
and  passed  through  the  flame  of  an  alcohol  lamp  imme- 
diately after  use,  and  certainly  before  use  upon  another 
person,  because  syphilitic  lesions  may  be  present, 
although  unrecognized.  Several  well-authenticated 
cases  have  come  under  my  observation  where  syphilis 
has  been  contracted  in  the  mouth  from  lack  of  proper 
care  in  this  regard.  Mucous  papules  are  very  often 
present  in  the  vagina  or  on  the  os  uteri  of  females  suf- 
fering from  acute  syphilis.  In  the  Independent  Practi- 
tioner for  March  of  this  year  may  be  found  a  report  of 
no  less  than  eight  cases  of  syphilis  of  the  finger,  in 
medical  men,  acquired  through  vaginal  examinations 
or  attendance  on  syphilitic  women  during  childbirth ; 
and  since  sending  in  that  report  I  have  seen  two  similar 
cases  occurring  in  the  resident  medical  staff  of  one  of 


So  PRACTICAL  CLINICAL  LESSONS   ON 

the  hospitals  of  this  city.  All  of  these  cases  were  fol- 
lowed by  constitutional  evidences  of  syphilis.  It  is 
scarcely  necessary  to  say  that  the  early  recognition  and 
local  treatment  of  mucous  papules,  patches,  or  tubercles, 
is  one  of  the  important  duties  attaching  to  the  manage- 
ment of  acute  syphilis.  Another  characteristic  lesion  of 
the  disease  consists  in  the  presence  of  scabs  in  the  hair, 
as  seen  in  this  patient.  The  discovery  of  scabs,  in  this 
locality,  sometimes  enables  us  to  make  a  positive  diag- 
riosis,  when  otherwise  we  would  be  in  doubt.  Alopecia, 
or  falling  of  the  hair,  is  one  of  the  common,  though 
not  constant,  concomitants  of  this  stage  of  the  dis- 
<ease.  It  is  readily  accounted  for  on  the  same  principle 
that  explains  the  exfoliation  of  the  epidermis  in  the 
syphilitic  papules.  The  crowding  of  newly  formed 
cells  in  the  vicinity  of  the  hair-bulbs  interferes  with 
their  nutrition.  It  is  not  at  all  unusual  for  a  patient  to 
lose  his  hair  completely,  including  his  eyebrows  and 
whiskers  ;  but  this  baldness  is  not  permanent,  since  on 
proper  treatment,  directed  to  the  removal  of  this  super- 
fluous cell  material,  the  hair  is  renewed.  We  find  that 
any  or  all  of  the  foregoing  lesions  Of  syphilis  may  be 
absent,  and  the  patient  yet  go  through  a  disease  which 
shall  be  recognized  as  syphilis.  In  other  words,  this 
disease  varies  in  its  intensity  as  much  as  any  other,  and, 
except  the  enlargement  of  the  lymphatic  glands,  none 
of  the  conditions  which  you  see  in  this  patient  are 
necessarily  essential  to  the  progress  of  syphilis.  This 
is  a  very  marked  case,  one  in  which  we  find  present 
more  than  the  usual  number  of  characteristic  lesions  or 
manifestations. 


SYPHILIS  AND  THE   GENITO- URINARY  DISEASES.     8 1 


LESSON  X. 

The  Treatment  of  Syphilis  in  the  Acute  Stage — Not  Addressed  to  a  Vague 
and  Conventional  Diathesis,  but  to  the  Removal  of  the  Material  shown 
to  be  Creating  Disturbance — All  Lesions  of  Active  Syphilis  the  Result 
of  Local  Crowding  of  Cells  at  Various  Affected  Points — The  Difficulty 
to  be  Remedied  a  Mechanical  One — Inquiries  as  to  the  Best  Method 
of  Removing  the  Superfluous  Cell  Material^— Fatty  Metamorphosis 
Alone  Capable  of  Effecting  this — Different  Methods  of  Producing  Fatty 
Degeneration  and  Elimination— Mercury  Proven  to  be  the  most  Po- 
tent Agent — Reasons  for  Using  it  in  Small  Doses  Long  Continued — 
Directions  in  Regard  to  the  Use  of  Mercury  in  its  Various  Forms — 
Internal  Administration — External  Use— Diet  in  Syphilis — Effects  of 
Rum  and  Tobacco  in  Retarding  the  Cure  of  Syphilis — Prof.  Willard 
Parker's  Advice. 

The  treatment  of  this,  as  well  as  all  cases  of  syphilis 
during  the  acute  stage,  will  be  addressed  to  the  removal 
of  the  material  which  is  causing  the  trouble.  That  is,  to 
the  superfluous  cell  growth  or  accumulation.  The  same 
material  that  we  find  in  the  initial  lesion,  and  the  same  as 
that  which  we  find  embarrassing  and  enlarging  the  gland 
structure.  The  same  as  in  the  papule.  The  same  as  in 
the  mucous  patch.  The  same  as  in  the  papules  which 
form  the  scabs  which  occur  in  the  hair.  These  lesions 
are  all  brought  about  and  kept  up  by  one  and  a  single 
condition,  namely,  that  resulting  from  an  abnormal  local 
proliferation  and  accumulation  of  germinal  cells.  This 
fact  has  been  substantiated  by  repeated  microscopical 
examinations  of  all  lesions  of  acute  syphilis.  Conse- 
quently, the  cause  of  all  the  several  conditions  or  lesions 
of  active  syphilis  being  the  same, — that  is  to  say,  an 
accumulation  of  this  embarrassing  cell  material, — the 
treatment  is  simple,  and  the  same  for  all,  having  simply 
for  its  object  the  removal  of  such  material. 

The  question  as  to  how  this  shall  best  be  effected 
leads  us  to  consider  first,  the  nature  of  the  material  we 
desire  to  be  rid  of.  This  has  been  proven  beyond  a 
question  to  consist  of  human  germinal  cells,  in  no  known 
respect  different  from  normal  germinal  cells,  except  that 


82  PRACTICAL   CLINICAL   LESSONS   ON 

they  are  the  product  of  a  proliferation  more  rapid  than 
that  process  under  normal  conditions.  Microscopically 
they  cannot  be  distinguished  from  the  cells  which  are 
proliferated  and  accumulated  to  repair  loss  of  normal 
tissue  brought  about  by  ordinary  causes.  Secondl}^ 
What  are  the  means  and  processes  by  which  healthy 
cell-material,  exuded  in  excess  of  the  necessities  of 
growth  and  repair,  is  removed  ?  The  answer  is  simply 
that,  the  necessary  process,  is  a  fatty  metamorphosis. 
Through  this,  alone,  any  living  material,  normal  or  ab- 
normal, must  pass  before  it  can  be  ehminated  from  the 
living  organism.  The  means  by  which  it  may  be 
effected  are  various  :  ist,  pressure  ;  2d,  innutrition  ;  3d, 
various  external  agents  and  internal  remedies,  which  by 
experiment  have  been  found  efficient  in  producing  or 
hastening  fatty  degeneration  or  metamorphosis  of  tissue. 

First,  in  regard  to  pressure:  The  effect  of  pressure 
in  producing  this  result,  is  recognized  in  its  known  influ- 
ence, as  a  surgical  measure,  in  reducing  and  dispersing 
abnormal  growths.  This  is  also  recognized  in  its  ten- 
dency to  spontaneous  disappearance,  after  a  time,  with- 
out treatment,  of  the  cell-accumulations  of  syphilis.  The 
tendency  of  all  syphilitic  lesions  is  toward  recovery. 
The  necessary  pressure  exerted  upon  any  local  cell 
accumulation  in  the  tissues  would  tend  toward  its  re- 
moval by  fatty  degeneration. 

Second,  in  regard  to  innutrition.  Withholding  of 
necessary  food  produces  fatty  degeneration  of  the  tis- 
sues. The  starvation  cure  was  at  one  time,  especially 
in  Germany,  in  great  repute  as  a  cure  for  syphilis.  The 
sweating  cure.  The  long  popular  and  much  vaunted 
cure  by  cathartics,  diuretics,  etc.,  through  profuse 
drinking  of  decoctions  of  sarsaparilla,  senna,  and  differ- 
ent woods,  can  now  be  recognized  as  influential  through 
their  capacity  to  hasten  fatty  metamorphosis.  But  the 
remedy  of  greatest  acknowledged  value,  in  the  treat- 
ment and  cure  of  syphilis,  for  the  past  two  hundred 
years,  and  up  to  the  present  da}^  is  we^-cury^  and  this,  it 
is  well  known,  is  also  the  most  efficient  agent  in  produc- 
ing fatty  metamorphosis  of  living  material.  Healthy- 
persons   quickly   emaciate,  all   kinds  of   tissues   break 


SYPHILIS  AND  THE  GENITO-URINARY  DISEASES.    83 

down,  under  its  continuous  excessive  use.  In  the 
salivation  it  then  produces,  the  characteristic  foetid 
odor  has  been  found  due  to  the  decomposed  fat  which 
results  from  the  fatty  degeneration  it  causes.  In  point 
of  fact,  every  remedy  which  has  ever  had  a  substantial 
reputation,  as  of  value  in  the  treatment  of  syphilis,  Avill 
be  recognized,  a  priori,  as  one  of  greater  or  less  power 
in  inducing  fatty  metamorphosis.  If  then  we  find  in 
syphilis,  as  the  characteristic  and  essential  factor  of 
every  lesion,  an  accumulation  of  superfluous  cell  mate- 
rial, sufficient  in  degree  to  embarrass  the  functions  of 
the  vessels  or  tissues  implicated,  we  have  good  reason 
to  introduce  the  remedy  which,  par  excellence,  is  known 
to  be  potent  in  removing  it,  namely,  mercury.  And  if  we 
consider  that  this  remedy  is  also  in  highest  repute  from 
a  clinical  standpoint,  we  are  warranted  to  proceed  in  its 
administration  with  the  expectation  of  the  best  possible 
results.  The  manner  of  its  use,  the  size  of  the  dose,  its 
frequency,  and  time  of  continuance  only  remain  to  be 
settled.  Clinical  experience  in  the  administration  of 
mercury  has  taught  the  fact,  now  accepted  by  all  recent 
recognized  authorities  in  matters  syphilitic,  that  small 
doses  of  mercury  continued  for  a  very  long  period,  say 
from  one  to  three  years,  constitute  the  best  treatment 
for  the  most  efficient  and  permanent  eradication  of  syph- 
ilis from  the  system  of  a  person  afflicted  with  that  dis- 
ease. This  applies  to  any  and  every  form  and  manifes- 
tation of  it  during  the  acute  stage,  which  stage  may 
be  said  to  cover  a  period  varying  in  different  cases  from 
one  to  three,  possibly  four,  years.  The  hastily  generated 
cell  material  which  has  been  described  as  the  essential 
element  in  the  production  of  the  different  manifestations 
of  syphilis,  lacks  the  healthful  vitality  to  enter  effect- 
ively into  the  composition  of  normal  tissues.  It  is  pres- 
ent only  as  obstructive  material,  and  from  its  presence 
as  such  is  already  subject  to  the  mechanical  influences 
which  tend  toward  its  dissolution.  It  may  then  be  ac- 
cepted as  more  readily  affected  by  remedial  measures 
calculated  to  induce  fatty  metamorphosis  of  living  mate- 
rial, than  such  material  generated  and  developed  under 
normal  conditions.    Hence  a  smaller  amount  of  mercury, 


84  PRACTICAL  CLINICAL  LESSONS  ON 

for  instance,  would  be  necessary  to  effect  its  removal 
from  the  affected  organism  than  would  be  required  to 
produce  a  like  effect  on  health}^  tissues.  Such  an  amount 
then  as  would  cause  the  speediest  removal  of  the  imper- 
fect or  syphilitic  material,  without  damaging  the  healthy 
constituents  of  the  body,  would  constitute  the  highest 
ideal  of  an  antisyphilitic  treatment.  Hence  we  can 
accept  from  an  inteUigent  and  philosophical  standpoint 
the  position  which  has  heretofore  been  only  taken  from 
a  clinical  or  empirical  view  of  the  matter,  viz.,  That 
small  doses  of  mercury,  long  co?iti7t2ied,  constitute  the  most 
effective  ajid  judicious  mode  of  treatment  of  syphilis  during 
its  active  stage. 

Beginning  then  with  small  doses,  of  whatever  prepa- 
ration of  mercury  we  decide  to  administer,  in  a  given 
case,  we  increase  the  amount  until  we  find  the  constitu- 
tion of  the  patient  being  affected,  evidenced  by  the  pres- 
ence of  softness  of  the  gums,  or  a  little  red  line  about 
them.  When  that  occurs,  we  know  we  are  getting  to  a 
point  of  affecting  the  healthy  structures  of  the  body,  and 
then  the  dose  is  reduced  until  just  that  point  is  reached 
at  Avhich  the  patient  can  be  carried  through  without  any 
disturbance  of  the  alimentary  canal  or  of  the  salivary 
apparatus.  In  the  case  of  this  patient,  then,  we  should 
commence  by  giving  small  doses  of  mercury,  gradually 
increasing  the  quantity  until  the  point  of  tolerance  is 
reached,  and  keep  it  there.  Any  of  the  preparations  of 
mercury  may  be  given.  We  will  begin,  say,  with  the 
protoiodide,  a  quarter  of  a  grain,  three  times  a  day  for 
two  or  three  days ;  or  lest  the  patient  should,  as  is  the 
case  with  some,  be  peculiarly  sensitive  to  the  influence 
of  mercur}^  we  may  begin  by  giving  only  two  pills  a 
day  for  two  or  three  days,  and  then  add  a  pill  at  a  time 
as  long  as  he  shows  no  evidence  of  disturbance  from  it, 
and,  when  the  highest  point  of  tolerance  is  reached, 
continue  the  dose.  Sometimes  blue  mass  with  iron  is 
used,  pills  containing  two  grains  of  the  mass,  hydrarg. 
with  one  grain  of  the  exsiccated  sulphate  of  iron — two 
to  four  daily  until  the  desired  impression  is  produced, 
and  continuing  usually  about  three  per  day  throughout 
the  desired  period.     In  all  these  cases  I  may  remark 


SYPHILIS   AND   THE   GENITO-URIxN'ARY   DISEASES.      85 

that  iron  is  indicated  because  the  health  is  usually  more 
or  less  below  par.  Therefore,  when  giving  the  proto- 
iodide  of  mercury,  I  am  also  in  the  habit  of  giving  the 
dialyzed  iron,  in  doses  of  ten  or  fifteen  drops,  three 
times  a  day.  The  biniodide  of  mercury  may  be  given 
in  doses  of  a  sixteenth  of  a  grain,  or  any  other  of  the 
preparations  of  mercury  may  be  administered  in  suit- 
able doses,  the  object  being  simply  to  get  the  gradual 
and  positive  effects  of  the  drug.  It  may  be  adminis- 
tered by  external  means,  using  a  small  quantity  of  mild 
mercurial  ointment,  say  the  size  of  a  filbert,  rubbing  it 
in  under  one  knee  one  night,  under  the  other  knee  the 
next  morning,  under  the  axilla  the  next  night,  and  so 
on,  using  it  night  and  morning.  There  have  been  those 
advocating  the  hypodermic  use  of  a  solution  of  the  bi- 
chloride of  mercury,  but  this  is  a  method  of  adminis- 
tering it  which,  while  I  have  used  it,  I  do  so  no  longer, 
and  do  not  recommend  it,  finding  other  quite  as  efficient 
and  more  agreeable  ways  of  introducing  mercury  into 
the  system.  Mercurial  baths  or  fumigations  may  also 
be  used  for  the  same  purpose. 

Whatever  be  the  form  of  mercurial  you  decide  upon 
employing,  your  treatment  should  be  conducted  accord- 
ing to  the  principles  I  have  mentioned  for  all  the  lesions 
or  manifestations  of  the  acute'  stage  of  the  disease. 
Whether  it  be  of  the  skin,  of  the  mucous  m.embrane,  or 
whether  it  be  a  syphilitic  iritis,  an  inflammation  of  the 
iris  (which  is  caused  really  by  a  papule  occurring  at 
that  point,  that  is,  an  accumulation  or  aggregation  of 
cells).  All  these  conditions  or  manifestations  of  syphi- 
lis, I  repeat,  respond  to  this  systematic  method  of  mer- 
curial treatment  better  than  to  any  other.  The  open 
lesions  during  the  acute  stage  of  syphilis,  chiefly  on 
raucous  membrane,  the  mucous  papules,  patches,  and 
tubercles,  before  alluded  to,  in  addition  to  constitu- 
tional measures,  require  prompt  local  treatment,  espe- 
cially on  account  of  the  contagious  property  of  their 
secretion.  Daily  applications  of  a  strong  solution  of 
nitrate  of  silver— forty  to  sixty  grains  to  the  ounce  of 
water  —  or  a  light  brushing  over  with  the  solid  arg. 
nit,  will  be  fgund  riiQ§t  efficacious  in  hastening  their 


86  PRACTICAL  CLINICAL   LESSONS   ON 

disappearance.     This  also  applies  to  ulcerations  of  the 
tonsils,  which  sometimes  occur  during  this  stage. 

When  papules  are  so  situated  as  to  cause  annoyance  by 
their  unsightliness,  as  on  the  face  or  hands,  ung.  hyd.  nit. 
or  ung.  hyd.  prsecip.  alb.  with  an  equal  quantity  of  cosmo- 
line,  or  a  ten  per  cent  solution  of  oleate  of  mercury  with 
equal  part  of  cosmoline  may  be  used  as  a  daily  local  ap- 
plication with  advantage.  In  the  latter  case  a  few  drops 
of  one  of  the  essential  oils  will  render  it  more  agreeable. 
The  diet  of  the  patient  should  be  simple,  excluding 
acids,  spices,  and  highly  spiced  food.  Tobacco  is  par- 
ticularly injurious  during  the  course  of  this  disease, 
from  the  fact  that  both  smoking  and  chewing  are  liable 
to  produce  irritation  of  the  mucous  m.embrane,  and 
when  a  mucous  patch  occurs  in  the  mouth  it  is  a  very 
difficult  thing  to  heal  while  its  contact  with  tobacco  is 
kept  up.  It  is  certainly  a  very  great  hardship  for  per- 
sons who  are  addicted  to  the  use  of  tobacco  to  give  it 
up  ;  but  it  is  very  important  that  they  should  do  so  for 
the  proper  and  effectual  treatment  of  this  disease.  In  a 
very  interesting  note,  received  not  long  since  from  the 
venerable  Professor  Willard  Parker,  in  which  he  spoke 
of  syphilis,  I  remember  he  very  quaintly  said  in  regard 
to  it,  "  Some  people  believe  that  syphilis  is  incurable ; 
that  is  not  my  belief.  When  a  patient  comes  to  me 
with  syphilis  1  say  to  him.  Do  you  use  tobacco  or  alco- 
holic spirits?  If  he  says  yes,  I  say  to  him,  You  are  pos- 
sessed of  three  devils — syphilis,  rum,  and  tobacco ;  if 
you  will  exorcise  two  of  them,  R.  and  T.,  I  will  take 
care  of  and  cure  the  other ;  but  if  you  will  not  agree 
with  me  to  give  assistance  in  this  way,  I  will  not  under- 
take your  case."  I  would  advise  you  all  to  make  a  note 
of  this  and  remember  Dr.  Parker's  advice.  I  can  assure 
3^ou  it  fully  coincides  with  my  own  opinion,  particularly 
in  regard  to  the  "  rum  ;"  and  in  regard  to  the  "  tobacco" 
also,  when  the  mucous  membrane  of  the  mouth  and 
throat  is  affected  or  predisposed  to  trouble. 


SYPHILIS  AND   THE   GENITO-URINARY  DISEASES.      8/ 


LESSON  XI. 

Case  I.  Clinical  Case  Illustrative  of  the  Initial  Lesion  Occurring  with- 
out Ulceration — Points  of  Value  in  Diagnosis  of  the  same — Treatment. 
Subsequent  History — Demonstration  of  Cure  through  Birth  of  Healthy- 
Children — No  Evidence  of  Syphilis  in  Twenty-nine  Years. 

Case  II.  Initial  Lesion  of  Syphilis  without  Induration,  and  without  Loss 
of  Tissue  "Parchment"  Variety — Any  Degree  of  Induration  may 
Present — Baumler's  Views. 

Case  III.  Saucer- shaped,  Non- Suppurating  Initial  Lesion,  with  Indurated 
Base  and  Edge — Description — Concomitants — Treatment — Subsequent 
History — Marriage — No  Subsequent  Trouble  in  Fifteen  Years. 

Case  IV.  Initial  Lesion  of  Meatus  Urinarius  Symptoms — Complicated 
with  Apparent  Chancroids — Their  Occurrence  found  due  to  Inflamed 
Initial  Lesion — Diagnostic  Points — Treatment — Secondary  Lesions — • 
Initial  Lesions  Aggravated  by  Local  Irritants — Sexual  Indulgence — 
Alcoholic  Stimuli. 

CLINICAL  CASES  FROM  MY  NOTE-BOOKS,  ILLUSTRATIVE 
OF  THE  VARIOUS  FORMS  WHICH  THE  INITIAL  LESION 
MAY  PRESENT  IN  CONSTITUTIONAL  SYPHILIS,  AND  OF 
THE  VARIOUS  LESIONS  ASSOCIATED  WITH  AND  FOL- 
LOWING THE   SAME: 

Case  I.  Induration  without  ulceration. — M.  W.  ;  aet. 
29;  merchant.  June,  1854.  History:  Never  had  any- 
previous  venereal  trouble.  Illicit  connections  with 
various  females,  at  intervals  of  a  week  or  two,  for  many 
years ;  no  suspicion  of  disease  especially  attaching  to 
any.  Noticed  a  little  abrasion  or  chafe  on  the  loose  tis- 
sue of  the  prepuce,  near  the  fossas  glandis,  in  the  median 
line,  which  healed  in  a  day  or  two  under  the  application 
of  a  little  Goulard  lotion.  Some  three  months  after, 
during  which  he  had  no  renewed  exposure  or  any  sus- 
picion of  trouble,  he  noticed  a  small  hard  painless  swell- 
ing on  the  site  of  the  former  abrasion,  and  some  sense 
of  fulness  in  the  groins,  which  attracted  his  attention, 
when  he  recognized  several  little  bunches,  not  before 
observed.  Was  under  the  impression  that  these  might 
be  due  to  strain  from  over  exercise,  and  called  to  inquiry 
if  they  needed  any  attention, 


88  PRACTICAL   CLINICAL   LESSONS   ON 

Examination  revealed  a  hard  kernel  in  the  cellular 
tissue  of  the  prepuce  at  the  point  before  noted,  movable 
and  not  sensitive.  Lymphatic  glands  of  both  inguinal 
regions  distinctly  enlarged,  some  size  of  a  small  bean  ; 
not  tender.  Tissues  of  pharynx  and  soft  palate  deeply 
congested.  Glands  along  the  posterior  border  of  the 
sterno-cleido-mastoid  muscle  enlarged  ;   not  tender. 

The  points  of  value  in  arriving  at  a  diagnosis  were 
as  follows : 

1st.  A  history  of  fracture  of  the  skin  or  semi-mucous 
membrane  resulting  from  a  suspicious  venereal  connec- 
tion. 

2d.  Subsequent  induration  at  that  point. 

3d.  Recent  painless  enlargement  of  the  inguinal 
glands,  or  those  nearest  to  the  suspected  point  of  inoc- 
ulation. 

4th.  Similar  enlargement  of  glands  at  a  distance,  as 
the  cervical. 

5th.   Congestion  of  faucial  region. 

Careful  examination  failed  to  discover  any  eruption 
on  the  skin  or  mucous  membrane.  Not  the  least  pain 
or  impairment  of  general  health  appreciated  by  the 
patient. 

Diagnosis. — Syphilis  in  the  so-called  secondary  stage. 
Allowing  twenty-one  d3.ys  as  the  usual  or  average  inter- 
val from  inoculation  to  induration  and  enlargement  of 
inguinal  glands,  and  forty  or  fifty  days  before  the  subse- 
quent general  gland  enlargements,  it  carried  the  initia- 
tion of  the  disease  back  at  least  two  months, which,  taking 
into  consideration  that  the  induration  was  quite  as  large 
as  a  small  pea  when  accidentally  discovered,  warrants 
the  conclusion  that  the  inoculation  of  syphilis  occurred 
at  the  date  of  the  abrasion  one  month  previous,  or 
three  months  from  the  time  of  its  discovery. 

The  patient  was  put  on  a  mild  mercurial  course  and 
kept  under  its  influence,  as  indicated  by  occasional  ten- 
derness of  the  gums  (when  it  was  alternated  with  iodide 
of  potassium),  for  fully  two  years.  The  congestion  of 
the  pharynx  continued  with  but  slight  change  for  sev- 
eral months,  when  a  sharply  cut  and  painful  ulceration 
occurred  in  both  tonsils.    This  was  treated  by  occa- 


SYPHILIS   AND   THE   GENITO-URINARY  DISEASES.      89 

sional  applications  of  the  strong  nitric  acid  and  solid  ni- 
trate of  silver  subsequently.  The  throat  continued  con- 
gested for  several  months  longer;  no  other  ulceration  or 
eruptive  lesion  at  any  point.  The  induration  occurring 
on  the  site  of  inoculation  did  not  disappear  entirely  for 
over  a  year.  At  the  end  of  the  second  year  the  gland 
enlargements  were  scarcely  perceptible,  and  the  treat- 
ment was  discontinued,  the  patient  remaining  free  from 
any  sign  of  disease  for  one  year  after.  Then  he  married. 
Subsequently  four  children  were  born  to  him.  At  this 
date,  September,  1882,  twenty-nine  years  have  elapsed. 
Patient  and  family  all  living  and  well.  Eldest  son,  28  ; 
next,  26 ;  next,  20 ;  daughter,  10:  no  one  of  them  having 
in  the  interval  had  any  recognized  manifestation  of 
syphilis ;  on  the  contrary,  have  all  been  exceptionally 
healthy  and  robust. 

Remarks. — Evidences  of  localized  cell  accumulation 
progressing  gradually  in  the  line  of  the  lymphatic  chan- 
nels, from  the  point  of  inoculation,  to  the  glands  in  the 
groin,  then  at  a  distance,  finally  involving  the  tonsils  to 
such  a  degree  as  to  interfere  with  the  processes  of  nu- 
trition and  production  of  a  sloughy  ulceration,  show 
that  the  case  was  unquestionably  one  of  syphilis.  It  is 
shown,  by  this  case,  that  syphilis  may  be  characteristic 
without  ulceration  or  recognized  general  eruption,  and 
it  will  be  found  in  following  the  history  of  other  cases 
that  the  ulceration  of  the  tonsils,  which  in  this  instance 
was  valuable  in  a  diagnostic  point  of  view,  is  more 
usually  absent,  and  hence  is  not  an  essential  but  an  ac- 
cident, without  which  the  foregoing  case  would  have 
been  free  from  all  ulcerative  lesions.  This  case  forms 
a  link  in  the  chain  of  evidence  which  goes  to  prove  that 
syphilis  is  curable,  that  the  contagious  element  of  the 
disease  is  limited  in  its  duration,  and  that  in  this  instance 
the  Hmit  did  not  exceed  three  years. 

Case  II.  Initial  lesio7i  without  characteristic  indurationy 
and  without  loss  of  tissue. —  Papular  eruption.  M.  L.; 
22  ;  printer.  Occasional  venereal  exposures:  presented 
with  a  well-marked  papular  eruption  on  the  forehead, 
also  sparsely  scattered  over  the  body,  arms,  and  legs ; 
denied   ever   having   any  sore.      Inguinal   glands   en^ 


90  PRACTICAL   CLINICAL  LESSONS   ON 

larged  and  painless  ;  in  cervical  region  the  same.  EpI- 
trochlear  gland  of  left  arm  as  large  as  a  marrowfat  pea. 
A  brownish  spot,  size  of  half-dime,  was  observed  on  the 
body  of  the  penis,  covered  with  fine  bran-like  scales. 
Patient  first  noticed  this  about  two  months  previously 
as  "  a  little  spot  of  scurf"  about  one  half  its  present  di- 
mensions ;  thought  it  was  of  no  consequence.  Integu- 
ment occupied  by  the  spot  slightly  but  distinctly  stiff- 
ened, giving  an  excellent  example  of  what  is  termed  by 
authors  the  parchment  induration,  and  characteristic  of 
a  somewhat  rare  form  of  the  initial  lesion  of  sj^philis. 
Patient's  general  health  unimpaired,  but  had  of  late  suf- 
fered with  headache  in  the  evenings,  chiefly  keeping 
him  awake  during  the  early  part  of  the  night,  and  pass- 
ing off  without  treatment.  Diagnosis  syphilis.  Initial 
lesion  of  parchment  variety.  Treatment:  B  pil.  duplex 
(2  grs.  mass,  hydrarg.  and  i  ferri  sulph.);  one  after  meals. 

Under  this  treatment  the  cephalalgia  disappeared 
in  the  course  of  a  couple  of  weeks.  The  eruption  on 
the  body  gradually  lost  its  papular  character,  leaving 
a  coffee  stain,  which  at  the  end  of  six  months  was  just 
visible ;  glands  less  in  size,  but  still  prominent.  Initial 
lesion  free  from  induration  and  scales,  but  still  of  tawny 
color  distinctly  marking  its  site.  Very  slight  redness 
at  border  of  gums.  On  several  occasions  there  had  been 
slight  sponginess  and  tenderness,  then  pills  by  direc- 
tion, had  been  suspended  for  a  few  days  and  again  re- 
sumed as  the  tenderness  disappeared ;  otherwise  the 
medicine  had  not  produced  any  sensible  disturbing 
effect.  Bowels  regular;  appetite  good  ;  general  health 
perfect. 

Remarks. — Baumler,  in  speaking  of  this  variety  of  the 
initial  lesion  of  syphilis,  says,  "  From  these  cartilaginous 
indurations"  (associated  with  and  characteristic  of  the 
ordinary  initial  lesion  of  syphilis)  ''  to  the  flat  paper-like 
thickening  of  the  mucous  membrane,  where  increased 
resistance  is  perceptible  only  in  feeling  of  it  sideways, 
all  imaginable  intermediate  stages  occur  ;  the  one  thing 
common  to  them  all,  being  a  dense  cellular  infiltration 
of  the  tissue  of  the  cutis  or  mucous  membrane."  * 

*  Ziemssen,  Am.  Ed.,  vol.  iii.  p.  iig. 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.      9I 

Case  III.  Saucer-shaped,  non-suppurating  initial  lesion^ 
with  indurated  base  and  edge. — H.  G.  A. ;  commercial 
traveller;  aged  31.  Nov.  15,  1867.  Suspicious  connec- 
tion about  two  months  previously ;  none  before  for  sev- 
eral months ;  none  subsequently.  Thinks  that  it  was 
about  four  weeks  after  when  he  accidentally  discovered 
a  little  "  chafe"  on  the  left  side  of  the  penis  just  behind 
the  glans.  This  he  treated  with  simple  water  dressings 
for  a  few  days,  when  he  saw  a  physician  who  pronounced 
it  syphilitic.  Cauterized  it ;  gave  him  a  lotion  to  apply 
on  a  little  lint,  and  ordered  pills  to  be  taken  for  several 
weeks. 

Under  this  treatment  the  "  chafe"  had  gradually  in- 
creased in  size,  and  presented  the  following  conditions : 
An  ulcer-like  lesion  about  the  size  of  a  half-dime ; 
edges  slightly  elevated,  rounded,  sloping,  forming  a 
saucer-shaped  concavity ;  the  floor  slightly  granular ; 
very  red  and  clean,  and  exuding  a  httle  transparent 
secretion,  which  under  the  microscope  was  found  to 
contain  only  large  epithelial  scales.  To  the  touch  the 
edge  and  base  of  lesion  was  hard  and  elastic,  and  mova- 
ble on  the  underlying  cellular  tissue.  It  represented 
the  typical  unirritated  initial  lesion  of  syphilis  often 
known  as  the  Hu7tterian  chancre.  The  lymphatic  glands 
in  either  groin  were  enlarged,  painless  on  pressure  ; 
several  the  size  of  a  small  bean ;  no  gland  enlargements 
in  the  cervical  region ;  no  trace  of  any  eruption  on  the 
body ;  throat  not  congested  ;  general  health  good. 

Diagnosis. — Syphilis  in  the  primary  or  initiative  stage. 

Treatment. — Pil.  duplex  thrice  daily  ;  local  application 
of  lotio  nig. 

Subsequent  History. — During  the  following  month  the 
patient  had  a  well-marked  roseolous  eruption,  which 
passed  off  within  a  few  days  without  in  any  way  affect- 
ing his  general  health.  A  group  of  lymphatic  glands 
became  enlarged  on  each  side  of  the  neck  ;  the  mucous 
membrane  of  the  throat  became  deeply  congested  and 
somewhat  sensitive. 

Under  the  treatment  above  noted,  the  local  lesion 
gradually  healed  and  the  induration  slowly  diminished, 
but  did  not  disappear  entirely  for  nearly  six  months, 


92  PRACTICAL  CLINICAL   LESSONS   ON 

and  then  left  a  slightly  juicy-looking  swelling  in  its 
place,  which  could  be  distinguished  for  fully  as  much 
longer. 

The  mercurial  treatment  as  above  noted  was  con- 
tinued steadily  for  a  full  year,  the  only  omission  being 
during  a  few  days  on  three  or  four  occasions,  when  in- 
creasing to  four  pills  per  day  the  gums  became  tender; 
otherwise  there  was  no  trouble  of  any  sort  referable  to 
the  medicine  or  the  disease.  Glands  still  distinctly  en- 
larged. During  the  second  year  a  combination  of  mer- 
cury with  the  iodide  of  potassium  was  given  (hyd.  bin- 
iodid.  yi^  gr. ;  potass,  iodid.  grs.  vjii.;  Mistura  biniodid. 
hydrarg.),  a  teaspoonful  three  times  daily  after  meals. 
At  the  end  of  this  year,  during  which  the  patient's 
health  had  been  excellent,  the  gland  enlargements  in  the 
inguinal  and  cervical  regions  had  entirely  disappeared ; 
there  w^as  not  the  slightest  trace  of  S37philitic  trouble 
at  any  point,  and  the  patient  was  discharged  cured. 
Married  two  years  subsequently  ;  two  children,  fourteen 
and  seven  years.  August,  1882;  no  trouble  to  which 
any  syphilitic  suspicion  could  attach  during  this  inter- 
val of  nearly  fifteen  3^ears. 

Case  IV.  Initial  lesion  of  the  meatus  urinarius. — H.  R. 
Inflamed  or  suppurating  chancre.  After  a  series  of 
impure  connections  a  smarting  on  urination  was  ob- 
served, and  on  examination  by  a  physician  slight  oozing 
of  mucus  from  the  urethral  orifice.  Was  treated  by 
injections  under  the  behef  that  he  had  contracted  a 
gonorrhoea.  Matters  continued  about  the  same  for  a 
few  days,  when  the  discharge  became  tinged  with  blood. 
This  led  to  an  examination,  which  revealed  a  small  point 
of  ulceration  just  within  the  meatus  urinarius.  On  the 
supposition  that  the  trouble  was  chancroid,  the  ulcer 
was  touched  repeatedly  with  nitric  acid  and  subse- 
quently treated  by  introduction  of  iodoform.  After  a 
persistent  trial  of  this  plan  for  about  three  weeks,  the 
difficulty  not  only  did  not  improve,  but  the  part  became 
very  tender  and  swollen  and  the  discharge  profuse  and 
purulent,  and  urination  very  difficult.  Several  small 
ulcers  at  length  appeared  on  the  inner  surface  of  the 
elongated  prepuce.     This  was  the  condition  of  things 


SVPHlLiS  AND  THE   GENITO-URINARY  DISEASES.     93 

when  the  patient  presented  himself  for  change  of  treat- 
ment. 

Attention  was  at  once  attracted  to  the  dense  indura- 
tion of  the  tissues  about  the  meatus,  also  to  the  presence 
of  well-marked  enlargement  of  inguinal  glans  on  both 
sides. 

The  glans  and  prepuce  were  swollen  and  intensely 
red.  An  ulceration  of  ragged  character  occupied  fully 
two  thirds  of  the  meatus  inferiorly,  and  extended  about 
one  third  of  an  inch,  as  determined  by  the  introduction 
of  a  small  meatoscope  (Otis's).  Three  small  sharply  cut 
ulcers,  the  largest  size  of  a  split  pea,  occupied  the  pre- 
putial opening — apparently  chancroids.  These  had 
occurred  over  a  month  from  the  date  of  any  venereal 
exposure,  and  more  than  three  weeks  from  the  dis- 
covery of  the  urethral  trouble.  This  was  opposed 
to  the  supposition  that  the  original  lesion  was  a  chan- 
croid. When,  however,  the  well-established  fact  that 
the  initial  lesion  of  syphilis,  under  prolonged  irritation, 
becomes  suppurative,  and  the  resulting  pus  has  the  con- 
tagious and  destructive  qualities  of  pus  from  a  true 
chancroid,  the  explanation  of  the  occurrence  of  appa- 
rent chancroids,  a  month  after  exposure  was  easy. 
This  was  also  a  suggestion  as  to  the  true  character  of 
the  original  lesion,  and  was  confirmed  by  the  recent  paiii- 
less  gland  enlargements  in  each  groin,  as  well  as  by  the 
characteristic  induration  associated  with  the  urethral 
ulcer.  The  patient  was  required  to  keep  the  recumbent 
position  for  a  few  days,  and  apply  a  lead  and  opium 
lotion  to  aid  in  reducing  the  inflammatory  complication. 
Iodoform  appHed  to  the  pseudo-chancroids  and  to  the 
initial  lesion,  and  the  patient  was  promptly  put  upon  a 
mercurial  course  (pil.  duplex,  one  thrice  daily).  Under 
this  treatment  the  ulcerations  external  to  the  urethral 
orifice  healed  within  a  few  days,  but  the  urethral  obstruc- 
tion, causing  by  the  swelling  and  induration  was  so 
increased,  that  sloughing  of  the  urethra  threatened, 
when  the  meatus  was  freely  divided  through  the  dense- 
ly indurated  tissues.  Immediate  amelioration  of  pain 
and  inflammation  resulted.  From  this  time  the  recov- 
ery from  the   local   troubles   progressed   rapidly,  and 


94  PRACTICAL  CLINICAL  LESSONS  ON 

gave  but  little  further  annoyance,  although  the  indura- 
tion remained.  In  another  fortnight  the  patient  called 
to  say  that  his  gums  were  a  little  tender,  and  also  that 
he  had  had  some  diarrhoea  for  a  few  days.  Evidently 
the  mercurial  was  in  excess,  and  he  was  directed  to  dis- 
continue until  these  troubles  had  passed  away.  Exam- 
ination of  his  body  at  this  time  revealed  a  well-marked 
roseola,  the  spots  of  which,  from  the  size  of  a  half-dime 
to  one  third  that  size,  were  distinct  on  the  breast,  back, 
and  arms.  Several  also  on  the  soles  of  the  feet,  and 
also  on  the  palms,  but  none  on  the  face,  or  back  of 
hands.  This  was  a  complete  surprise  to  the  patient, 
although  he  had  been  instructed  to  look  out  for  it,  and 
he  was  confident  that  it  had  not  been  present  more  than 
twenty-four  hours,  and,  except  for  the  diarrhoea,  ex- 
pressed himself  as  having  felt  perfectly  well.  Enlarge- 
ment of  glands  in  the  cervical  and  epitrochlean  regions 
was  now  distinct. 

Nothing  further  of  moment  occurred  for  the  follow- 
ing weeks,  and  the  patient  was  in  fair  condition,  taking 
three  pil.  duplex  daily ;  when  at  about  the  middle  of 
the  third  month  (from  the  discovery  of  his  trouble)  he 
began  to  complain  of  headache  at  night,  keeping  him 
awake  until  nearly  morning,  then  passing  off  and  re- 
turning on  the  following  night,  and  he  complained  of 
a  general  malaise^  and  this  w^ithout  any  recognized 
excess  or  error  in  diet.  A  small  superficial  ulceration 
was  discovered  on  the  right  side  of  the  tongue,  and 
another  about  the  size  of  a  three-cent  piece  on  the  right 
anterior  pillar  of  the  fauces.  Some  few  scabs  were  also 
discovered  on  the  scalp.  On  again  examining  his  body 
the  faint  coppery  stains  of  the  roseola  were  seen  here 
and  there  over  the  body,  and  in  addition  to  this  a 
few  red  elevated  papules,  not  more  than  a  dozen  in 
number,  were  discovered  scattered  over  the  body  ; 
none  on  the  face,  hands,  or  feet. 

Pills  continued.  The  superficial  ulcerations  (mucous 
patches)  in  the  mouth  were  daily  touched  with  a  forty- 
gr.  sol.  of  nit.  arg.  In  a  week  the  patient  was  in  his 
usual  condition  ;  the  papules  passed  off  in  about  a 
month,  leaving  some  slight  yellowish  stains.     No  recur- 


SYPHILIS   AND   THE   GENITO-URINARY  DISEASES.      95 

rence  of  mucous  patches.  Continued  the  pills  up  to 
date  of  departure  from  town,  July  i,  1882,  at  which 
date  he  had  been  under  treatment  for  twelve  full 
months,  and  at  the  time  had  no  trace  of  induration 
about  the  site  of  the  initial  lesion,  no  trace  of  the 
eruptions,  nothing  left  to  indicate  his  syphilitic  trou- 
ble, except  the  still  easily  recognized,  though  greatly 
decreased  gland  enlargements  in  the  groin,  in  the  cer- 
vical and  right  epitrochlean  regions.  That  in  the  left 
epitrochlean  space  at  time  of  discovery  about  the  size 
of  a  pea  had  quite  disappeared.  Ordered  mist,  biniodid. 
for  at  least  six  months,  and  then  to  report  for  further 
orders. 

Remarks. — The  result  of  persistent  irritation  of  a  sim- 
ple initial  lesion  of  syphilis  is  well  shown  in  the  fore- 
going case.  Also  the  fact  that  sores  simulating  true 
chancroids  may  arise  simply  from  contact  with  the  pus 
from  an  initial  lesion  of  syphilis,  the  normal  secretion 
from  the  latter  being  only  composed  of  serum  and  the 
debris  of  epithelial  material. 

It  will  be  observed  that,  in  this  case,  the  appearance 
of  the  roseola  was  not  preceded  by  any  pecuhar  sensa- 
tion on  the  part  of  the  patient,  while  that  of  the  later 
papular  eruption  was  associated  with  characteristic 
preliminary  disturbance.  This,  however,  is  in  all  pro- 
bability due  to  the  gradual  obstruction  of  lymphatic 
glands  throughout  the  system,  and  not  to  any  special 
influence  of  the  papular  eruption;  for  it  will  be  observed 
that  here,  as  in  similar  cases,  the  appearance  of  the 
eruption  did  not  relieve  the  malaise  of  the  patient,  as 
is*  the  case  under  similar  circumstances  in  the  eruptive 
fevers.  It  will  be  observed  that  this  case  varies  from  the 
preceding  ones  in  that  the  characteristic  eruptions  of 
the  active  stage  were  present.  As  we  proceed  it  will 
appear  that  no  two  cases  are  quite  similar  in  regard  to 
the  variety  or  degree  of  concomitant  manifestations  ; 
but  it  will  also  be  found  that  in  all  cases  the  lymphatic 
gland  enlargements  play  a  prominent  part,  and  that, 
as  their  presence  is  the  most  important  and  significant 
evidence  of  the  presence  of  syphilis,  their  gradual  and 
finally,  their  complete  disappearance,  is  the  surest  evi- 


96  PRACTICAL   CLINICAL   LESSONS   ON 

dence  of  the  complete  disappearance  and  virtual  cure 
of  syphilis.  Finall}^  it  may  be  stated  in  regard  to  the 
inflammatory  complication,  present  in  the  foregoing 
case,  that  this  is  likely  to  occur  in  any  initial  lesion  of 
syphilis  from  the  persistent  application  of  irritants,  such 
as  nitrate  of  silver,  sulph.  copper,  etc.,  or  from  friction 
by  the  clothing.  Its  occurrence  is  favored  by  the  scrof- 
ulous diathesis,  by  sexual  excitement,  and  by  irregular 
living  and  alcoholic  stimuli. 


SYPHILIS  AND   THE   GENITO-URINARY   DISEASES.      97 


LESSON   XII. 

Clinical  case — Phagedenic  form  of  the  Initial  Lesion  and  its  physical  pecu- 
liarities—Treatment by  mercurials — Rapid  healing  under  their  influ^ 
ence — Phagedena  of  Chancroid  influenced  unfavorably  by  mercurials 
— Subsequent  history,  showing  results  of  insufScient  treatment  in  early 
stage — Early,  steady  and  prolonged  treatment  the  only  trustworthy 
means  of  preventing  later  lesions  of  the  disease — Inability  to  bear  the 
mercurial  treatment  very  rare — Cures,  in  properly  treated  cases,  estima- 
ted at  95  per  cent. 

Case  V.  Gaitgrenous  mitial  lesion^  or  so-called  pha^ 
gedenic  chancre^  followed  by  mucous  patches ;  death  by 
cerebral  softejting. — L.  K.,  drug  clerk,  aged  21  ;  of  scrofu- 
lous diathesis  and  dissipated  habit ;  presented  with  an 
inflamed  ulcer  about  as  large  as  a  three-cent  piece, 
shaped  somewhat  like  the  figure  8,  partly  on  the  glans 
penis  (left  side),  and  encroaching  upon  the  fossse  glandis, 
and  situated  upon  a  densely  indurated  base.  The 
floor  of  the  ulcer,  which  was  apparently  about  a  line 
in  depth,  was  of  a  yellowish  gray  color,  of  a  shreddy 
appearance,  exhaling  the  peculiar  sickening  odor  of 
gangrenous  tissue.  Glands  of  either  groin  enlarged  and 
hard;  no  other  signs  of  disease.  He  gave  a  history  of 
great  sexual  and  alcoholic  excess  prolonged  over  several 
weeks  ;  the  discovery  of  a  sore  on  his  glans  penis  about 
a  fortnight  previous,  and  daily  touchings  with  blue 
stone,  on  his  own  responsibility.  He  fancied  he  was  get- 
ting better  when  he  went  off  on  a  spree  of  several  days' 
duration,  having  occasional  sexual  connections  in  the 
time.  For  the  last  two  days  there  had  been  considera- 
ble pain,  and  he  had  been  applying  iodoform  in  powder, 
i  he  induration,  which  was  very  dense,  extended  about 
two  or  three  lines  from  the  edge  of  the  ulcer,  where  it 
met  quite  abruptly  the  swollen  tissue  surrounding  it. 
Diagnosis :  gangrenous  initial  lesion  of  syphilis.  The 
fact  that  simple  sores  and  also  chancroids  become  indu- 
rated by  applications  of  caustics,  and  even  of  simple 
astringents  in  some  cases,  was  borne  in  mind ;  but  the 


98  PRACTICAL   CLINICAL   LESSONS    ON 

recent  well-marked  and  painless  gland  enlargements  in 
the  inguinal  regions  were,  when  taken  in  connection  with 
the  history  and  condition  of  the  lesion,  considered  suffi- 
cient proof  of  its  syphilitic  origin  to  warrant  the  test  by 
a  mercurial  course.  The  patient  was  sent  to  bed,  pow- 
dered charcoal  poultice,  sprinkled  with  iodoform  as  dis- 
infectant and  sedative,  and  calomel  in  yV"§'^-  doses  was 
administered  every  hour  during  the  day,  not  continu- 
ing it  through  the  night ;  and  when  i|-  grains  had  been 
taken  the  patient's  gums  were  distinctly  tender  and 
the  medicine  was  omitted.  The  slough  extended  until 
the  entire  induration  was  destroyed,  it  was  removed, 
within  a  few  days,  and  showed  a  healthy  granulating 
surface.  The  mercurial  was  continued  in  the  form  of 
the  proto-iodid,  hyd.  in  pills  of  half  a  grain  each,  and 
healing  took  place  in  about  a  month,  leaving  scarcely  a 
trace  of  induration,  but  a  soft,  juicy-looking  swelling, 
about  the  size  of  the  original  lesion,  in  its  place.  Some 
swelling  and  tenderness  of  the  submaxillary  glands  oc- 
curring, the  mercurial  was  entirely  omitted,  and  the 
patient  put  upon  cod-liver  oil  and  iron.  Not  seen  again 
for  nearly  six  mionths,  when  he  reported  with  mucous 
patches  on  the  soft  palate  and  gland  enlargements  in 
cervical  region  well  marked.  Again  put  on  the  mer- 
curial treatment,  and  this  time  by  nightly  rubbing  in  ^ 
dram  of  ung.  hydrarg.  mixt.  under  the  arms  and  knees 
alternately.  The  mucous  patches  were  touched  with 
the  solid  arg.  nit.  After  about  a  fortnight  the  patches 
being  quite  healed,  the  gums  scarcely,  if  at  all,  affect- 
ed, the  right  submaxillary  gland  began  to  inflame, 
and  in  spite  of  local  applications,  of  immediate  cessa- 
tion of  the  mercurial,  and  the  administration  of  iodine 
and  cod-liver  oil,  it  went  steadil}''  on  to  suppuration. 
The  patient  here  passed  from  observation.  Some  three 
years  after  he  was  reported  as  having  several  epileptic 
seizures,  finally  dying  of  cerebral  ramolissement. 

Remarks. — The  early  prominent  feature  in  this  case 
is  the  gangrene  occurring  in  the  initial  lesion.  Auspitz,* 


*  Anatomic  d.  Syph. :    Initial  Sklerose,     Von  Prof.  H.  Auspitz  u.  Dr. 
PaulUnna.     Vierteljahrschrift  f.  Derm.  u.  Syph,  (1876),  s.  161. 


SYPHILIS  AND   THE   GENITO-URINARY  DISEASES.      99 

Unna,*  Beisiadccki,f  Verson,  Kaposi,  and  others  have 
shown  that  the  induration  of  the  initial  lesion  is  depend- 
ent upon  a  dense  infiltration  of  cells  and  development  of 
fibrous  tissue  which  interferes  more  or  less  with  the 
vessels  of  nutrition.  Complete  obstruction  occurring  in 
certain  cases,  gangrene  results  as  in  the  foregoing  case, 
and  is  essentially  different  from  the  molecular  gangrene 
of  chancroid,  which  is  the  result  of  the  destructive  nature 
of  the  lesion  per  se.  Hence  the  treatment  by  mercu- 
rials, which  tends  to  produce  fatty  metamorphosis  of  the 
obstructive  material  in  the  initial  lesion  of  syphilis,  and 
thus  relieve  the  cause  of  necrosis,  is  indicated ;  while 
in  gangrene  or  phagedenia  occurring  in  the  chancroid 
the  mercurial  influence  Avould  tend  to  hasten  the  de- 
structive action. 

The  fact  that  the  slough  was  confined  to  the  indu- 
rated mass,  and  that  healing  went  rapidly  on  under  the 
mercurial  treatment,  is  in  confirmation  of  the  foregoing 
view. 

The  inability  to  bear  a  mercurial  treatment  may  rea- 
sonably be  attributed  to  the  scrofulous  diathesis,  and 
this  aggravated  by  every  sort  of  dissipation  and  impru- 
dence. The  father  of  this  patient  died  of  chronic  phthi- 
sis, and  this  patient  had  had  swellings  of  cervical  glands 
without  suppuration  some  years  previous.  The  occur- 
rence of  epilepsy,  and  subsequent  death  from  brain  dis- 
ease, (which  was  designated  cerebral  softening,)  in  a 
young  man  of  twenty-four  years,  can  safely  be  consid- 
ered a  legitimate  sequel  of  syphilis.  It  is  reasonable  to 
believe  that,  had  the  patient  been  able  to  bear  a  pro- 
longed and  systematic  course  of  treatment  by  mercu- 
rials, he  would  have,  in  all  probability,  escaped  the 
trouble  which  caused  the  fatal  issue. 

In  the  recent  work  of  Hill  and  Cooper,  of  London 
(1881),  prominent  English  authorities,  the  following 
statement  occurs  :  ''  There  is  also  p:ood  foundation  for 

*  Zur  Anatomic  der  Syphil. :  Initial  Sklerose.  Vierteljahrschrift  f. 
Derm.  u.  Syph.  (1878),  s,  531. 

f  Archives  of  Acad.  Sciences,  1867,  (Ods's  Physiology,  Pathology, 
and  Treatment  of  Syphilis,  New  York:  Putnam.  1881.)  Vienna,  1873. 
Vol.  i.,  p.  53. 


loo  PRACTICAL  CLINICAL  LESSONS   ON 

the  belief  that  steady,  prolonged  mercurial  treatment, 
although  not  an  infalUble  means,  is  the  only  trustworthy 
one  for  preventing  a  return  of  the  disease." 

Bumstead  and  Tajdor,  in  their  late  work*  (New 
York,  1879),  g"0  so  far  as  to  say  that  *' we  know  that 
the  great  majority  of  cases  (estimated  as  high  as  95 
per  cent)  which  have  been  thoroughly  treated  are 
absolutely  cured,  and  are  never  followed  by  a  relapse." 
It  is  not,  then,  easy  to  estimate  the  gravity  of  the  misfor- 
tune to  one  who,  having  acquired  syphilis,  is  unable  to 
bear  a  systematic  mercurial  treatment.  With  judicious 
management  such  cases  are  fortunately  rare. 

*  Fourth  Ed.,  1879,  p.  810. 


SYPHILIS  AND   THE   GENITO-URINARY   DISEASES.    lOI 


LESSON   XIII. 

Clinical  case — Initial  Lesion  complicated  with  Herpes  and  Phimosis — Dif- 
ficulties in  diagnosis — Treatment — Contagious  character  of  secretions 
from  all  fractures  of  skin  or  mucous  membrane  during  active  stage  of 
Syphilis — Falling  of  hair  due  to  cell  accumulations  about  hair  bulbs — 
Polymorphous  character  of  Syphilis  in  some  cases — Absence  of  charac- 
teristic lesions  in  others. 

Case  VI. — Initial  lesion,  occurring  up07i  herpes  and  com- 
plicated with  phimosis.  Followed  by  roseola,  m  ucous patches ^ 
and  alopecia.  — Yi.  T.,  merchant,  34,  had  suffered  on  fre- 
quent occasions  during  several  years  with  herpes  pre- 
putialis,  the  httle  watery  vesicles  of  which  would  ap- 
pear sometimes  independently  of  any  venereal  exposure, 
and  again  would  follow  such  exposure  within  three 
or  four  days.  In  several  instances  the  vesicles  be- 
came pustules,  and  small  ulcers  were  formed ;  but 
through  the  use  of  the  simple  lead  lotion  recovery 
had  always  taken  place  within  a  few  days,  except 
in  a  single  instance,  when  it  was  fully  a  fortnight  in 
healing,  and  there  was  said  to  have  been  much  swell- 
ing and  hardness.  His  prepuce  was  redundant  and 
habitually  covered  the  glans  penis,  but  was  readily  re- 
tracted and  was  kept  scrupulously  clean,  as  he  had  long 
previously  found  that  inattention  to  this  favored  the 
production  of  the  herpes.  Occasional  venereal  connec- 
tions were  indulged  in,  with  great  care  taken  to  secure 
immunity  from  disease.  The  only  person  with  whom 
connections  had  been  had,  for  three  months  previous, 
was  with  one  who  was  thought  entirely  above  suspicion 
of  having  any  venereal  trouble.  A  fortnight  previous, 
three  or  four  days  after  last  connection,  a  group  of  her- 
petic vesicles  appeared.  These  were  on  the  inner  layer 
of  the  prepuce,  at  its  attachment  near  the  frenum,  on 
the  left  side.  They  were  treated  as  usual  with  the  lead 
water  and  disappeared  within  a  few  days,    with  the 


103  PRACTICAL   CLINICAL   LESSONS   ON 

exception  of  two  points  which  pustulated,  and  finally, 
when  about  the  size  of  a  small  split  peppercorn,  coa- 
lesced. Had  much  necessary  walking  to  do,  and  the 
parts  after  about  ten  days  became  so  swollen  that  the 
prepuce  was  retracted  only  with  pain  and  difficulty. 
Still  certain  that  the  trouble  was  a  simple  herpes,  aggra- 
vated by  his  exercise  and  by  a  rather  debilitated  gen- 
eral condition  from  overwork,  he  sought  advice  only  as 
to  herpes.  This  was  about  four  weeks  subsequent  to 
his  last  connection. 

Condition  on  presentation,  June  lo,  1878,  as  follows: 
In  good  general  health,  but  somewhat  debilitated  from 
overwork.  Penis  somewhat  turgid  and  reddened  ;  pre- 
puce redundant,  covering  glans.  Orifice  contracted 
so  that  the  glans  could  not  be  exposed.  Pressure  be- 
tween the  fingers,  just  at  the  base  of  the  glans  on  the 
left  side,  showed  some  slight  condensation  of  the  tis- 
sues and  caused  some  pain,  and  oozing  of  shght  muco- 
purulent fluid.  Two  inguinal  glands  about  size  of  a 
marrowfat  pea  in  left  groin.  No  amount  of  argument 
would  persuade  the  patient  that  his  difficulty  was  likely 
to  prove  different  from  the  attacks  of  herpes  with  which 
he  was  familiar,  and  he  declined,  almost  indignantly  the 
suggestion  that  an  examination  of  his  paramour  should 
be  made  in  order  to  aid  in  determining  the  exact  nature 
of  his  difficulty.  Absolute  rest  on  the  lounge  or  in  bed  and 
injections  of  weak  lead  and  opium  wash  to  thoroughly 
lave  the  preputial  cavity  was  continued  for  the  next 
two  weeks.  The  attempts  to  retract  the  prepuce  gave 
so  much  pain  that  it  was  no  longer  attempted.  Under 
the  rest  and  sedative  treatment  the  soreness  diminished, 
but  an  induration,  which  was  appreciated  in  some  de- 
gree on  first  examination,  was  now  increased,  and  the 
two  glands  in  the  left  groin,  one  above  and  the  other 
below  Poupart's  ligament  (and  which  had  been  stren- 
uously insisted  on  as  the  result  of  strain  occurring  a 
long  time  previous),  were  evidently  increasing  in  size 
and  were  slightly  tender  on  pressure  ;  besides  this  sev- 
eral smaller  glands  were  now  appreciated  on  the  op- 
posite side.  With  these  strong  evidences  of  syphi- 
litic trouble,  the  patient  was  finally  persuaded  to  sub- 


SYPHILIS   AND   THE    GENITO-URINARY   DISEASES.    IO3 

mit  to  a  mercurial  treatment,  commencing-  with  pil. 
proto-iodid.  hyd.  J  grain,  three  times  daily,  and  15 
drops  Wyeth's  dialyzed  iron  in  a  glass  of  milk,  while 
the  same  local  applications  were  continued.  On  the  third 
day  pills  every  six  hours.  At  the  end  of  a  week  the 
tenderness  of  the  local  lesion  was  scarcely  perceptible, 
and  the  swelhng-  less  prominent.  Glands  no  longer 
sensitive  on  pressure.  No  effect  of  the  mercurial  seen 
in  the  mouth,  but  a  slight  intestinal  irritation  causing 
two  or  three  fluid  passages  from  the  bov/els,  ^  grain  of 
the  watery  extract  of  opium  was  added,  and  a  dram  of 
ung.  hyd.  mit.  ordered  to  be  rubbed  alternatel}^  into 
each  thigh  every  night.  No  further  intestinal  trouble. 
The  preputial  swelling  and  tenderness  decreased  so 
much  within  the  next  fortnight  that  the  prepuce  was 
retracted  (though  with  some  difficulty),  discovering  on 
its  inner  surface  a  superficial  erosion  about  as  large  as 
a  five-cent  piece,  set  in  a  distinct  and  characteristic 
disc  of  indurated  tissue.  Slight  tenderness  of  gums 
appearing,  the  ointment  was  suspended,  and  pills  (J  gr. 
protoiodid.)  reduced  to  four,  omitting  the  opium,  which 
had  caused  slight  constipation. 

July  5th  (seven  weeks  after  last  connection),  the  ulcer 
had  quite  healed,  but  the  induration  remained  promi- 
nent. The  patient  called  attention  to  a  bright  rosy 
eruption  which  was  distributed  profusely  over  the 
body,  a  few  spots  on  the  face  and  palms.  Glands  in  the 
cervical  region  distinctly  enlarged  ;  size  varying  from 
a  buckshot  to  a  No.  4;  one  especially  prominent  on 
either  side  of  the  ligamentiim  nuchae.  Left  epitrochlean 
size  of  small  pea ;  right,  not  discoverable.  Mercurial 
well  borne  ;  no  tenderness  of  gums,  but  a  slight  red 
line  was  seen  at  the  border  of  the  gums  of  several  teeth. 
Has  had  some  soreness  of  throat.  Examination  shows 
right  tonsil  inflamed  and  somewhat  swollen  ;  fauces 
deeply  congested  ;  patient  advised  to  leave  off  smoking. 
Ordered  sat.  sol.  potass,  chlorat.  to  be  used  as  a  gargle 
and  habitual  wash  for  the  mouth,  teaspoonful  to  a  tum- 
bler of  water,  three  or  four  times  a  day. 

July  30.  Has  continued  the  medicine  steadily.  Rose- 
ola faded  out  in  about  two  weeks  leaving  scarcely  a  trace  ; 


104  PRACTICAL   CLINICAL  LESSONS   ON 

soreness  of  throat  also  passed  off  leaving  the  parts  still 
congested,  but  free  from  tenderness  ;  smokes  occasion- 
ally ;  does  not  think  it  affects  his  throat ;  gums  not 
affected. 

August  10.  Calls,  complaining  of  return  of  throat 
trouble ;  otherwise  doing  well.  Examination  shows  a 
small  patch  of  superficial  ulceration  on  the  right  side  of 
the  soft  palate,  bordered  with  a  narrow  gray  line  ;  also  a 
small  crack  in  the  mucous  membrane  at  the  left  angle  of 
the  mouth.  Explain  the  importance  of  such  lesions : 
viz.,  that  mucous  patches  or  any  cracks  in  mucous  mem- 
brane, of  whatever  character,  during  the  first  year  of 
syphilis  at  least,  give  rise  to  a  contagious  secretion,  and 
when  brought  in  contact  with  an  abrasion  in  a  health}^ 
person,  on  the  lips  or  elsewhere,  will  communicate 
syphilis. 

Touch  the  ulcerations  with  solid  nit.  arg.  very 
lightly,  just  to  whiten,  and  recommend  that  this  be 
repeated  daily  until  tlieir  complete  healing.  Also  as 
gums  are  not  at  all  red  or  tender,  increase  pills  again  to 
four  daily  and  prohibit  smoking  entirety,  as  the  effect  of 
tobacco  always  is  to  aggravate  and  prolong  syphilitic 
difficulties  of  the  mouth  and  throat.  Patient  complains 
of  his  hair  falling  out;  wishes  to  know  if  this  is  due  also 
to  his  disease.  State  that  it  certainly  is,  but  that  under 
faithful  pursuance  of  his  treatment  this  as  well  as  the 
other  difficulties  will  in  all  probability  be  but  temporary. 
A  stimulating  wash  was  given  for  the  hair. 

The  subsequent  history  of  this  patient  presented  no 
salient  features.  His  acute  throat  trouble  passed  off  in 
a  few  days,  but  the  faucial  mucous  membrane  continued 
congested  for  many  months.  The  alopecia,  which  in 
some  cases  extends  to  entire  loss  of  hair,  eyebrows, 
etc.,  in  this  instance  was  never  sufficient  to  attract 
attention.  The  induration  on  the  site  of  the  initial 
lesion  gradually  became  smaller,  but  was  not  entirely 
gone  for  quite  a  year  from  the  date  of  its  appear- 
ance, although  the  treatment  was  kept  steadily  up, 
scarcely  missing  a  dose,  giving  as  much  as  the  patient 
would  bear  without  producing  tenderness  or  red- 
riess  of  the  gums,  or  irritation  of  the  bowels ;  this  was 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.    10$ 

from  three  to  six  pills  of  the  proto-iodide  during  each 
twenty -four  hours  for  a  little  more  than  a  year.  At  this 
time  all  evidences  of  cell  accumulation  at  the  site  of  the 
initial  lesion  had  entirely  disappeared.  The  glands  in 
the  groins  were  still  slightly  enlarged,  but  those  in  the 
cervical  and  left  epitrochlean  regions  had  quite  gone. 
Was  very  anxious  for  consent  to  marry,  but  advised  to 
a  twelve  months'  course  of  what  is  familiarly  known  as 
the  mixed  treatment — Mist,  biniodid.  hydrarg.  contain- 
ing -^  biniodid.  and  8  grs.  potass,  iodid.  thrice  daily. 
This  was  taken  faithfully,  and  borne  without  trouble 
of  any  sort.  Six  months  after  this,  he  not  having  seen 
any  evidences  of  his  former  trouble  for  over  a  year,  and 
as  the  inguinal  glands,  although  slightly  enlarged,  were 
not  greater  than  many  Avho  have  never  had  syphilis, 
consent  was  given  to  his  marriage — about  two  years 
and  a  half  from  date  of  acquirement  of  the  disease.  A 
short  time  since  he  called,  having  been  happily  married 
for  over  two  years,  to  state  that  he  had  had  not  the 
sHghtest  return  of  his  old  trouble,  nor  had  his  wife  con- 
tracted any  disease ;  his  only  trouble  was  that,  as  yet, 
he  had  had  no  children. 

Remarks. — The  occurrence  of  an  initial  lesion  on  the 
site  of  a  herpes  preputialis,  as  shown  in  the  foregoing 
case,  is  not  infrequent.  On  the  contrary,  there  is  no 
more  favoring  condition  for  the  acquirement  of  syphilis 
than  a  predisposition  to  herpes.  A  slightly  irritant 
leucorrhceal  discharge  is  often  sufficient  to  determine 
an  attack,  and  the  bland  and  unirritating  nature  of  the 
disease  germ  of  syphilis  does  not  interfere  with  the 
natural  course  of  the  herpes.  It  should  never  be  lost 
sight  of  that  no  lesion  occurring  after  an  illicit  vene- 
real contact  can  be  safely  pronounced  free  from  dan- 
ger of  having  been  the  point  of  entrance  of  a  syphilitic 
disease  germ  until  after  the  longest  period  which  has 
been  known  to  elapse  between  inoculation  and  the  ap- 
pearance of  the  initial  lesion,  and  this  is  never  less 
than  forty  days. 

Second  point  of  especial  moment  is  the  prompt  effect 
of  the  mercurial  treatment  in  reducing  the  tenderness 
and  swelling,  not  alone  of  the  initial  lesion  but  of  the 


Io6  PRACTICAL   CLINICAL   LESSONS   ON 

adjacent  glands,  adding-  proof  to  the  position  that 
mercury  acts  on  the  newly  proliferated  syphilitic  cell 
material  which  distends  and  disturbs  the  tissues,  in- 
ducing a  fatty  metamorphosis,  (through  which  alone 
living  material  can  be  eliminated  from  the  organism,) 
and  aids  also  in  deciding  between  opposing  authorities, 
some  of  whom  ^  claim  that  mercury  should  be  withheld 
as  a  rule  until  the  manifestation  of  constitutional  syph- 
ilis appears ;  while  others  f  claim  that  the  treatment  by 
mercury  should  be  commenced  as  soon  as  the  initial 
lesion  can  be  recognized  as  such.  Certainly,  if  mer- 
cury acts  in  curing  syphilis  through  any  property  it 
is  known  to  possess,  it  is  by  its  power  to  hasten  tissue 
metamorphosis  or  fatty  degeneration ;  and  if  it  has 
this  value  in  the  cell  accumulations  of  the  so-called 
secondary  manifestations,  it  cannot  be  denied  in  the 
accumulations  constituting  the  initial  lesion,  which  has 
been  shown  by  such  authorities  as  Cohn,  Beisiadecki, 
and  others,  to  be  virtually  identical  in  composition  and 
nature  with  them.  Hence  we  are  prepared  to  agree 
intelligently  with  those  who  begin  the  treatment  of 
syphilis  at  the  earliest  moment  of  its  recognition. 

The  usual  tolerance  of  mercurials,  given  in  doses,  and 
with  the  frequency  sufficient  to  produce  a  mild  and 
curative  effect,  is  well  shown  in  the  foregoing  case. 

It  will  be  observed  that  the  papular  eruption,  which 
often  occurs  about  the  third  or  fourth  month  of  syphi-. 
lis,  was  apparently  absent.  Its  equivalent  was,  however, 
recognized,  in  the  mucous  patches  in  the  mouth,  and  in 
the  alopecia,  which  is  found  by  microscopic  examination 
to  result  from  accumulation  of  cells  about  the  hair 
bulbs,  similar  to  those  forming  the  papule  on  the  skin 
in  other  cases.  The  polymorphous  character  of  syphilis 
in  the  acute  stage  is  well  seen  in  this  case,  but  it  will 
be  found  that  no  two  cases  are  alike  in  the  number, 
locality,  or  degree  of  development  of  their  manifesta- 
tions, and  that  cases  may  even  be  met  which  pass 
through  the  different  stages  of  the  disease  without  pre- 


*  Bumstead  and  Taylor  ("Venereal  Diseases."     Philadelphia:  1879), 
f  Hill  and  Cooper  (London  :  1881), 


SYPHILIS  AND   THE    GENITO-URINARY   DISEASES.    10/ 

senting  a  single  characteristic  lesion  of  the  skin  or 
mucous  membrane ;  the  only  evidence  of  syphilis  being 
confined  to  gland  enlargements  (often  escaping-  obser- 
vation), and  the  subsequent  occurrence  of  well  marked 
sequelas  of  syphilis. 


I08  PRACTICAL  CLINICAL  LESSONS   ON 


LESSON  XIV. 

Clinical  case — Initial  Lesion  on  the  lip — Simulating  Epitheliama;  also  the 
mucous  patch  —Dark  color  of  papular  eruption  on  a  quadroon — Rose- 
ola passing  off  in  48  hours — Malposition  of  Epitrochlean  Gland — Ease 
with  which  enlarged  glands  sometimes  escape  discovery — Subsequent 
papular  eruption — Occurrence  of  Iritis  due  to  same  cell  accumula- 
tion as  produces  the  papule — Treatment  for  all  lesions  in  the  active 
stage  of  Syphilis  the  same — New  troubles  not  an  evidence  of  relapse, 
but  incidents  en  route — Treatment  of  Iritis — Persistence  of  the  papular 
eruption  Characteristics — Recurrence  after  disappearance,  and  in  same 
spots  formerly  occupied — Continued  recurrences — Significance  of  this — 
Question  of  marriage  a  difficult  one  in  such  cases — State  of  papular 
eruptions  significant  of  changes  previously  effected  in  the  skin  where 
papules  occupy  spots  of  previous  eruption,  and  suggestive  of  non-con- 
tagiotis  stage. 

Case  VII.  btitial  lesion.  Mucoid  form,  simulating  a 
mticoits  patch.  Large  papulo-pustular  eruption.  Iritis — 
Acquired  from  woman  with  7nucous  patches  and  a  mili- 
ary papular  eruption.  A.  W.,  chemist,  38,  presented 
December,  1878,  for  an  opinion  as  to  the  nature  of  a 
small  superficial  ulcer  just  inside  the  lower  lip,  near 
the  right  labial  commisure.  Patient  had  suffered  oc- 
casionally with  "  cold  sores"  about  the  lips,  and  thought 
the  trouble  of  that  nature,  until  a  medical  friend  sug- 
gested that  it  might  be  a  commencing  epithelial  can- 
cer, the  result  of  excessive  smoking,  and  ought  to  be 
shown  to  a  surgeon.  Two  surgeons  had  examined 
the  sore,  one  of  whom  was  confident  that  it  was  an 
epithelioma ;  the  other  thought  it  doubtful,  and  sug- 
gested syphilis,  and  advised  him  to  get  another  opin- 
ion. The  lesion  was  nearly  circular,  and  about  as 
large  as  would  be  covered  by  the  top  of  an  ordinary 
lead  pencil;  its  surface  was  slightly  elevated,  florid, 
granular,  and  covered  with  a  grayish  pelHcle.  The 
tissues  on  which  it  was  situated  were  quite  hard  to  the 
touch,  for  perhaps  a  quarter  of  an  inch  surrounding. 
But  for  this  induration  it  could  not  have  been  distin^ 
guished  from  a  typical  mucous  patch.     Two  slightly 


SYPHILIS  AND   THE   GENITO-URINARY   DISEASES.    IO9 

enlarged  lymphatic  glands  lying  over  the  parotid  were 
found  ;  none  at  any  other  point.  The  patient  denied  ever 
having  had  syphilis,  or  any  sexual  connection  for  more 
than  a  year,  but  admitted  kissing  a  female  domestic  in 
his  family  on  several  occasions.  No  other  evidence  of 
trouble  was  found.  After  much  argument  the  gentle- 
man at  last  consented  to  send  the  domestic  for  examina- 
tion. She  proved  to  be  a  very  handsome  quadroon, 
very  simple,  and  evidently  unaware  of  having  any 
venereal  disease.  She  admitted  that  she  had  had  some 
sore-throat  and  a  profuse  leucorrhoea,  but  denied  ever 
having  had  sexual  intercourse ;  denied  also  having 
had  any  sores  of  an}^  sort,  except  an  occasional  "  can- 
ker" in  the  mouth.  Examination  revealed  an  exten- 
sive superficial  irregular  ulceration  of  the  soft  palate, 
bordered  with  the  diphtheric  deposit  characteristic  of 
the  syphilitic  mucous  patcJi.  She  had  also  well-marked 
gland  enlargements  in  all  the  usual  localities,  and  a 
miliary  papular  eruption  over  the  body.  The  papules 
Avere  about  the  size  of  a  large  pin's  head,  in  groups  of 
6  to  8  or  10,  an  inch  or  more  apart,  and  appeared  on  the 
light  coppery  skin  of  the  quadroon  as  of  a  deep  purple 
color.  At  first  claiming  that  she  had  always  had  these 
dark  points,  she  finally  confessed  that  they  had  appeared 
only  two  or  three  months  previous,  and  also  that  she 
had  had  a  single  illicit  connection  some  months  before, 
but  stoutly  denied  all  knowledge  of  having  had  any 
local  disease. 

With  this  positive  knowledge  of  syphilis  and  the 
strong  circumstantial  evidence  which  it  afforded,  there 
was  but  little  room  to  doubt  that  the  suspected  epithe- 
lioma of  the  lip  was  an  initial  lesion  of  syphilis,  acquired 
throu;^h  contact  with  a  mucous  patch ;  the  secretion 
of  which,  as  well  as  all  the  secretions  throughout  the 
active  stages  of  syphilis,  being  well  known  to  possess 
the  contagious  property  equally  with  the  open  initial 
lesion  of  syphilis. 

Mr.  W.  was  satisfied  to  commence  a  systematic  mer- 
curial course,  as  advised.  Pil.  duplex  (hyd.  mass.  2  grs  ; 
fcrri  exsic  i  gr.)  was  taken  steadily  for  about  a  month, 
at  the  rate  of  three  per  day,  without  any  trouble  of  any 


no  'i^RACTICAL  CLINICAL  LESSONS   ON 

sort,  except  slight  tendency  to  fluid  passages  from  the 
bowels,  which  was  readily  corrected  by  a  little  pare- 
goric. Having  been  instructed  to  watch  carefully  for 
any  eruption,  he  called  within  a  few  days,  with  a 
slight  mottling  of  the  skin  on  back  and  abdomen,  so 
indistinct,  however,  it  was  quite  uncertain  whether  this 
was  anything  more  than  the  natural  spottiness  which  is 
not  uncommon  in  cool  weather.  Gland  enlargements  in 
the  cervical  region  were  now  distinctly  made  out ;  none 
in  the  inguinal  or  epitrochlean. 

On  the  following  day,  by  careful  inspection,  looking 
across  the  back,  and  also  the  abdomen,  against  a  strong 
light,  a  pale  eruption,  slightly  elevated  in  places,  made 
it  quite  certain  that  it  was  the  roseola,  initiating  the 
constitutional  stage  of  syphilis.  It  passed  off  com- 
pletely, however,  very  soon,  for  48  hours  afterwards  it 
could  not  be  certainly  detected  at  any  point. 

It  is  worthy  of  note  here,  that  another  careful  exam- 
ination for  an  enlarged  epitrochlean  gland  resulted  in 
its  discovery  fully  the  size  of  a  marrowfat  pea,  and 
situated  at  least  three  inches  above  the  epitrochlean  space, 
between  the  borders  of  the  biceps  and  triceps  muscles. 
The  knowledge  that  such  malposition  is  not  very  urn 
common,  and  that  quite  large  glands,  having  sometimes 
very  loose  attachments,  will  slip  under  the  borders  of 
muscle  or  fasciae  in  such  a  way  as  to  elude  any  but  the 
most  careful  and  persistent  search,  may  occasionally  be 
serviceable. 

During  the  next  few  weeks  nothing  noteworthy, 
except  congestion  of  the  faucial  mucous  membrane, 
which  at  times  Avas  quite  swollen  and  sensitive,  but  tem- 
porarily relieved  by  chlorate  of  potash  gargle,  and  occa^ 
sional  sprajdng  with  a  40-gr.  solution  of  argent,  nit. 
Finally,  two  or  three  small  superficial  ulcers  occurred 
on  the  tonsils,  and  at  about  the  same  time  some  redness 
and  pain  in  the  left  ej^e,  which  had  been  quite  weak  for 
a  day  or  two.  Examination  showed  some  conjuncti- 
vitis, the  iris  slightly  discolored  and  duller  than  the 
opposite,  and  on  closing  and  opening  the  lids  quickly, 
with  aid  of  a  thumb  on  either  eye,  it  was  seen  that 
the  iris  of  the  left  eye  was  nearly  immovable ;  and,  as 


SYPHILIS  AND   THE   GENlTO-URINARY  DISEASES.    Ill 

if  it  were  not  sufiBcieiit  to  have  discovered  this  well- 
marked  example  of  a  mild  type  of  syphilitic  iritis,  it 
was  also  found  that  a  scanty  eruption  of  papules,  some 
as  large  as  silver  three-cent  piece,  had  developed  on 
the  back,  arras  and  legs ;  not  the  least  irritation  an- 
nounced their  presence ;  they  were  rosy  in  color, 
slightly  elevated,  and  quite  insensitive  to  touch.  The 
patient  was  very  despondent  from  this  combination  of 
ills  until  assured  that  the  trouble  with  the  throat,  the 
eye,  and  the  integument,  were  simply  evidences  of  the 
same  papular  eruption,  modified  by  locality  ;  an  accu- 
mulation of  cells  which  had  caused  a  disturbance  by 
their  presence,  chiefly  mechanical,  and  which,  with  the 
aid  of  the  treatment,  would,  in  all  probability,  pass  off 
in  a  short  time  without  leaving  any  permanent  trace. 
That  they  were  not  evidences  that  the  treatment  thus 
far  pursued  was  unsuitable  or  inefficient ;  but  that,  in 
the  necessity  of  avoiding  damage  to  healthy  struc- 
tures, the  process  of  destroying  and  eliminating  this 
imperfect  cell '  material,  accumulated  in  the  mucous 
membrane  of  the  throat,  in  the  iris,  and  in  the  skin,  was 
a  comparatively  slow  but  a  sure  one.  That  nothing 
else  was  necessary  but  to  go  steadily  on  with  the  mer- 
curial. In  just  that  amount  and  frequency  as  could  be 
borne  without  damage  to  the  sound  material  and  tis- 
sues in  which  they  were  imbedded.  That  these  new 
troubles  were  not  the  evidence  of  a  relapse  or  coming 
anew  under  the  syphilitic  influence,  as  manifested  in 
the  apparently  arrested  and  transient  roseola.  They 
were  simply  incidents,  adverse  currents,  or  shoals,  if  you 
will,  on  the  onward  voyage  towards  recovery  ;  that 
while  many  made  this  voyage  with  scarcely  a  ripple 
of  discomfort  from  beginning  to  end,  others  met  with 
varying  obstructions  and  delays ;  but  all  eventually 
passed  through,  and  few  comparatively,  if  well  guided 
to  its  termination,  found  themselves  much  the  worse  for 
the  experience.  The  distillation  of  a  couple  of  drops  of 
a  solution  of  atropine  (2  grains  to  the  ounce  of  distilled 
water)  into  the  affected  eye,  had  the  almost  immediate 
effect  of  demonstrating  that  slight  adhesions  of  the  iris 
to  the  anterior  capsule  of  the  lens  had  taken  place, 


112  i>ractical  clinical  lessons  on 

irregularity  in  border  of  the  iris  becoming  visible. 
This,  however,  soon  gave  way  under  a  few  repetitions 
of  the  atropine,  at  intervals  of  three  or  four  hours,  which 
also  relieved  the  pain.  The  attack  proved  a  very  slight 
one,  for  no  other  treatment  became  necessary ;  and  after 
continuing  the  dilatation  by  atropine  for  a  couple  of 
weeks,  and  simply  avoiding  a  strong  light,  all  evidences 
of  the  trouble  had  disappeared.  The  initial  lesion  and 
the  induration,  never  extensive,  had  quite  disappeared. 
The  papular  eruption  remained,  and  although  the  mer- 
curial was  well  borne,  and  an  occasional  sense  of  tender- 
ness of  the  gums  announced  the  limit  of  endurance  of  the 
remedy.  At  the  end  of  another  month  it  had  not  entirely 
lost  its  salience,  although  it  had  quite  lost  its  reddish 
color  and  assumed  a  deep  coppery  hue.  Occasional 
papules  showed  an  exfoliation  of  the  epidermis  at  their 
base,  which  condition,  resulting  from  the  interference 
with  nutrition  through  the  cell  accumulation  causing 
the  papule,  constitutes  a  valuable  point  in  diagnosis. 
With  a  steady  continuance  of  the  treatment,  however, 
the  spots  gradually  disappeared,  having  continued  (from 
the  date  of  their  appearance  until  they  could  no  longer 
be  detected)  fully  three  months.  Nothing  then  occurred 
to  interrupt  the  favorable  course  of  the  trouble  in  this 
case — throat  trouble  having  gradually  faded  out :  the 
gland  enlargements  almost  gone.  After  nearly  a  year, 
however,  the  treatment  in  the  period  having  been  faith- 
fully pursued  as  initiated,  small  scaling  papules  ap- 
peared. These  were  flat,  slightly  thickened  spots,  rather 
than  papules,  about  the  size  of  a  lead  pencil  top,  with 
their  silvery  border  of  epidermal  scales,  when  discov- 
ered, and,  had  it  not  been  for  previous  histor}^,  could 
not  have  been  distinguished  from  spots  of  simple  pso- 
riasis. There  had  been  on  each  hand  only  a  very  few 
spots  of  the  original  papular  eruption,  say  five  or  six, 
and  had  caused  the  chief  discomfort  of  the  patient  at 
one  time,  as  they  constituted  the  only  evidence  of  syphi- 
lis to  a  casual  observer.  On  this  account  they  had 
received  quite  a  little  local  treatment  by  mild  mercurial 
unguents,  and  with  apparent  success,  as  they  passed 
off  at  least  a  month  before  those  on  the  body.     The 


SVPHILIS  AND   THE   GENITO-URINA'RY  DISEASES.    11^ 

statement  (which  the  patient  made  quite  confidently) 
that  these  spots  had  returned  in  the  exact  places  occupied 
by  the  former  eruption  was  noted.  Similar  carefully- 
observed  cases  which  had  been  met,  where  a  return  of 
such  an  eruption  over  three  years  (in  one  instance)  after 
the  original  papular  eruption,  and  in  the  same  places^ 
seemed  to  indicate  that  the  later  eruption  might  belong 
rather  to  the  sequelae  of  syphilis  than  to  the  evidences 
of  the  active  contagious  disease.  And  the  treatment 
was  changed  from  the  simple  mercurial  to  the  combina^ 
tion  of  mercury,  with  the  iodid.  of  potass.  (Mist,  binio^ 
did.  hydrarg.,  see  page  259.)  A  few  weeks  of  this  treat- 
ment, added  to  ung.  hydrarg.  nit.  and  vaseline,  equal 
parts,  locally,  caused  entire  disappearance  of  this,  and 
after  three  months  further  treatment  with  the  misturse 
biniodid.  (3  three  times  a  day),  it  was  suspended  from 
accidental  causes  for  nearly  a  month,  when  the  spots 
returned,  and  apparently  071  the  exact  sites  of  the  former 
spots.  Treatment  resumed,  with  the  addition  of  a  fumi* 
gation  thrice  weekly,  thirty  grains  of  resublimed  calo- 
mel, (this  preparation,  on  account  of  its  less  irritant 
property,  being  preferred),  and  moderate  inspiration  of 
the  vapor  advised,  if  it  could  be  borne  without  pro- 
ducing cough. 

Again,  within  a  few  weeks,  the  spots  disappeared,  and, 
as  the  gums  became  slightly  tender,  the  fumigation  was 
omitted,  continuing  the  "Misturse  Biniodid."  alone.  The 
patient  then  went  on  living  very  regularly,  and  taking 
his  medicine  as  ordered,  and  with  scrupulous  care,  as 
he  was  under  engagement  of  marriage  formed  just  pre- 
vious to  his  inoculation,  and  desirous  of  hastening  his 
recovery  in  every  possible  way.  After  six  months  of 
this  treatment,  in  order  to  test  his  condition,  he  omitted 
his  medicines  and  the  spots  returned  in  less  than  a  fort- 
night. This  was  the  only  evidence  of  the  syphilitic  dia- 
thesis now  remaining,  for  the  throat  had  long  since 
ceased  to  show  any  unusual  engorgement,  and  the 
glands  in  all  localities,  while  still  distinguishable,  were 
no  longer  characteristic.  Another  six  months,  making 
fully  two  years  from  the  date  of  his  inoculation,  and  the 
patient  presented  very  worried,  stating  that  while  he 


114  PRACTICAL   CLINICAL   LESSONS   ON 

was  quite  well  in  every  other  respect,  and  had  no  trouble 
of  any  sort  when  he  took  his  medicine,  as  soon  as  he  left 
off  treatment,  the  scaly  spots  would  return  on  his  hands, 
and  always  in  the  same  places.  He  was  very  anxious 
for  some  definite  time  to  be  set  when  it  would  be  safe 
for  him  to  marry.  It  became  necessary  to  advise  this 
patient  that,  in  the  present  state  of  knowledge  in  regard 
to  such  a  relapsing  eruption  following  syphilis,  it  was 
uncertain  whether  or  not  any  contagious  element  was 
still  associated  with  it ;  that  the  active  stage  of  syphi- 
lis was  one  of  steady  progression,  while  the  sequelae 
were  prone  to  relapses.  That  the  repeated  recurrence 
of  the  scaling  spots  on  the  same  sites  were  significant 
rather  of  organic  change  in  the  vessels  of  nutrition  in 
the  affected  integument  than  of  an  infecting  material 
free  in  the  blood  ;  but  inasmuch  as  there  was  not  suffi- 
cient available  experience  to  decide  this  point  positively 
it  would  be  necessary  for  him  to  postpone  his  marriage 
indefinitely,  and  go  on  with  his  treatment  until  the  ces- 
sation of  it,  as  tested  from  time  to  time,  was  not  followed 
by  a  recurrence  of  the  trouble.  Then,  according  to 
best  authorities,  he  should  wait  a  full  year,  which,  if 
passed  without  evidence  of  syphilitic  trouble,  he  might 
venture  to  consider  himself  well,  and  marry.  This  pa- 
tient is  now  two  and  one-half  years  from  the  date  of 
inoculation,  and  has  passed  nearly  three  months  with- 
out treatment  or  any  return  of  trouble. 

Remarks. — The  occurrence  of  the  syphilitic  initial 
lesion  on  the  lip  is  not  very  rare.  In  the  foregoing  case 
the  contagion  was  undoubtedly  direct,  but  this  is  the 
point,  more  than  any  other,  where  the  initial  lesion  may 
be  looked  for  as  a  result  of  mediate  contagion,  viz.,  con- 
tact as  of  the  lips  with  any  articles  which  have  been  in 
use  by  persons  who  have  mucous  patches  on  the  lips  or 
in  the  mouth  or  fauces.  Hence,  when  syphilis  is  sus- 
pected, and  the  site  of  the  initial  lesion  in  doubt,  this  re- 
gion should  be  examined  with  great  care.  The  presence 
of  enlarged  lymphatic  glands  in  the  vicinity  is  of  great 
value  in  clearing  up  a  diagnosis,  for  these  are  rarely,  if 
ever,  absent  in  sj^philis  beyond  the  third  or  fourth  week 
after  inoculation,  and  may  often  be  found  at  a  much 


SYPHILIS  AND   THE    GENITO-URINARY  DISEASES.    I15 

earlier  period.     (For  explanation  of  manner  in  which 
mucoid  form  of  initial  lesion  is  formed  see  page  108.) 

Various  modifications  of  the  papular  eruption  of 
syphilis  will  be  met,  no  two  cases  presenting-  exactly 
the  same  arrangement,  locality,  or  degree  of  develop- 
ment. The  miliary  variety  where  the  papules  are  about 
the  size  of  a  pin's  head,  sharply  acuminated,  and  often 
into  a  little  serous  accumulation  or  a  scale  at  the  sum- 
mit, and  thickly  and  irregularly  distributed,  or  in  groups 
(like  that  described  in  the  female  associated  in  the  fore- 
going case),  or  arranged  in  circles  or  figures  of  8.  Again, 
the  papules  may  be  large  and  flat  in  groups,  or  thickly 
and  generally  distributed,  or  sparsely  (as  in  the  above 
case  of  A.  W.),  but  to  a  certain  extent  always  symmetri- 
cal on  either  side  of  the  median  line  of  the  body — a  fact 
which  characterizes  the  early  papular  eruption  as  con- 
tra-distinguished from  that  sometimes  occurring  in 
groups  and  unsymmetrically  at  a  later  period,  as  towards 
the  end  of  the  first  year  of  infection,  or  subsequently. 
Papules  may  be  associated  with  pustules ;  may  all  be 
more  or  less  pustular ;  may  even  begin  apparently  as 
pustules  ;  and  thus  a  great  variety  of  eruptions  of  a  papu- 
lar or  papulo-pustular  character  may  be  met  in  the  early 
period,  say  from  the  third  to  the  sixth  month  after  in- 
fection. The  presence  of  such  eruptions,  whether  we 
designate  them  after  authorities  by  the  size  or  shape 
of  the  papules,  or  according  to  their  real  or  supposed 
resemblance  to  simple  diseases  of  the  skin,  as  the  lich- 
enoid, the  lenticular,  the  scaling  papular  (syph.  psoria- 
sis), the  annular  (syph.  lepra),  or  the  acneiform,  the 
variola  form,  the  impetigo  form,  or  the  ecthyma  form, 
we  must  nevertheless  bear  constantly  in  mind  the  fact 
that  one  and  all,  if  of  syphilitic  origin,  are  the  result 
of  the  localized  accumulation  of  cell  material,  hastily 
generated  through  the  syphiUtic  influence ;  taking  the 
different  forms  through  constitutional  idiosyncrasies  or 
dyscrasias,  and,  according  to  the  late  microscopic  re- 
searches of  Kohn,  Auspitz,  Virchow,  Neuman,  Baum- 
ler,   always    beginning   in   a   papillae    cutis,*  and   that 

*  See   Otis  on  "Physiology,  Pathology,  and   Treatment  of  Syphilis;" 
Putnams,  1881,  p.  33. 


Il6  PRACTICAL   CLINICAL   LESSONS   ON 

the  treatment  for  all  is  the  same,  varied  in  degree  only, 
to  suit  the  constitutional  peculiarities  of  each  case. 
It  is  also  proper  to  state  that  no  eruption  can  be  pro- 
nounced syphilitic  from  its  appearance  alone,  but  that, 
in  order  to  warrant  such  opinion,  gland  enlargements 
must  also  be  present  more  or  less  pronounced  in  the 
various  localities  where  the  superficial  lymphatic  glands 
are  located,  as  in  the  cervical,  inguinal,  and  epitrochlear 
regions.  It  will  also  be  seldom  that  other  evidences 
are  not  also  present,  one  or  more,  such  as  congestion  of 
the  throat,  ulceration  of  tonsils,  mucous  patches  in  the 
mouth,  or  between  the  toes,  or  at  the  anus.  It  is  then 
evident  that  the  form,  color,  size,  or  locality  of  an  erup- 
tion is  not  the  test  as  to  its  nature,  but  it  must  always 
be  traced  to  a  probable  syphilitic  origin  before  it  is 
warrantable  to  pursue  a  systematic  mercurial  course. 
That,  so  traced,  every  variety  of  eruption  of  a  papu- 
lar, pustular,  or  vesicular  character,  or  any  combination 
of  these  forms  occurring  between  the  second  and 
seventh  months  after  a  syphilitic  inoculation  may  be 
said  to  have  its  cause  in  a  localized  cell  accumulation 
beginning  in  a  papil^  cutis.  For  the  elimination  of  this, 
a  gentle  persistent  mercurial  treatment  is  indicated  not 
only  as  the  result  of  clinical  experience,  but  from  the 
fact  that  it  is  *'  the  remedy,  par  excellence,  for  inducing  the 
fatty  metamorphosis :  through  zvhicJi  alone  the  cell  accumti- 
lations  occurring  during  the  acnte  stage  of  syphilis  can  be  re- 
moved!' 

Papular  eruptions,  and  their  variations,  in  the  early 
stage  are  sometimes  slow  in  reaching  their  full  develop- 
ment, varying  usually  several  days  and  sometimes  as 
many  weeks,  but  there  are  apparently  no  relapses,  the 
new  accessions  appearing  always  at  new  points.  The 
so-called  relapses  coming  on  soon  after  the  disappear- 
ance of  the  first  crop  of  papules,  coming  as  they  usually 
do  in  groups,  would  seem  to  be  due  to  the  setting  free 
of  infectious  material  stored  in  temporarily  obstructed 
lymphatic  glands.  In  other  cases  where  the  eruption 
recurs  at  same  points  (as  in  present  case,)  this  would 
seem  to  be  due  to  changes  in  the  skin  from  previous 
damage,  and  may  ultimately  have  to  be  classed  among 


SYPHILIS  AND   THE   GENITO-URINARY   DISEASES.    11/ 

the  sequelcE  rather  than  among  the  manifestations  of  the 
active  period  of  syphilis,  or  that  in  which  a  contagious 
element  is  still  present  in  the  blood  and  in  the  secre- 
tions of  all  lesions.  Further  observations  on  this  point 
will  be  presented  when  considering  the  later  periods  of 
the  disease. 


U8  PRACTICAL   CLINICAL   LESSONS   ON 


LESSON  XV. 

Clinical  case — Hunterian  Chancre — Treatment  by  excision — Mode  of 
operation — Ulcerating  papular  eruption — Mucous  patches  and  papules 
— Treatment — Unfavorable  influence  of  tobacco  and  alcohol — Good 
effect  of  Syphilis  on  habits  of  patient — Treatment  well  borne — Length 
of  time  required  to  keep  it  up — Time  when  immunity  from  danger  of 
communicating  the  disease  arrives — Length  of  probationary  period 
before  marriage — Causes  and  conditions  which  occasion  pustulation 
and  ulceration  in  the  papular  eruptions  of  Syphilis. 

Case  VIII.  Initial  lesion.  Papulo- pustular  eruption^ 
mucous  patches^  and  papules,  etc. — G.  M.,  aged  i8;  bar- 
tender ;  presented  with  a  characteristic  specimen  of  the 
so-called  Hunterian  chancre  on  the  superior  aspect  of 
a  redundant  prepuce.  The  open  lesion  was  fully  three- 
fourths  of  an  inch  in  length  by  one-third  of  an  inch  in 
breadth,  imbedded  in  a  cartilaginous  matrix  about  a 
quarter  of  an  inch  broader  and  longer,  and  moveable  on 
the  inner  reflexion  of  the  prepuce.  This  had  been  sev- 
eral months  in  coming  to  these  dimensions — not  quite 
certain  as  to  time ;  appearing  first  as  a  slight  chafe  and 
gradually  increasing  in  size  and  density  under  a  variety 
of  local  applications — caustic  and  sedative.  No  inter- 
nal treatment  had  been  resorted  to.  Glands  in  groin 
and  cervical  regions  enlarged  and  hard.  No  history 
of  previous  veneral  disease.  General  health  not  very 
good,  but  no  particular  pain  or  trouble  except,  latterly, 
occasional  headaches,  sometimes  in  the  day  but  chiefly 
at  night.  Examination  shows  a  large,  deep  red  papu- 
lar eruption  rather  thickly  scattered  on  the  back  and 
breast  chiefly,  but  on  the  thighs  pustules  were  present 
about  the  size  of  a  split  pea,  scabbed  and  surrounded 
by  a  slight  inflammatory  areola,  while  on  the  legs,  es- 
pecially near  the  ankles,  were  several  superficial  ulcer- 
ations covered  with  brown  scabs  as  large  as  a  dime, 
looking  very  angry  an4  sensitive.  Also  several  points 
of  superficial  ulceration  between  the  toes,  the  sur- 
rounding surface  presenting  a  whitish  sodden  appear- 


SYPHILIS   AND   THE    GENITO-URINARY   DISEASES.    II9 

ance,  the  secretions  very  offensive  (mucous  patches). 
Besides  these  were  several  moist  papules,  quite  ele- 
vated, and  open  pustules  on  the  scrotum  (mucous  pa- 
pules and  tubercles,  simple  and  ulcerated).  The  throat 
was  deeply  congested,  but  neither  this  nor  the  mouth 
presented  any  localized  lesion. 

Diagnosis:  Syphilis,  in  the  fourth  or  fifth  month. 

Treatment :  As  the  initial  lesion  was  easily  movable 
on  the  underlying  cellular  tissue,  its  enucleation  was  de- 
cided upon.  After  the  parts  had  been  thoroughly 
cleansed  and  bathed  with  a  one  to  sixty  solution  of  car- 
bolic acid,  the  indurated  mass  was  tightly  encircled  by 
a  small  silver  wire,  and  the  tissues  beneath  it  transfixed 
with  a  sharp  pointed  bistoury,  cutting  out  first  one  half 
and  then  the  other,  thus  removing  the  entire  mass. 
Half-a-dozen  turns  of  continuous  suture  of  black  thread 
closed  the  wound  satisfactorily,  and  a  simple  wet  bo- 
rated  cotton  dressing  was  applied.  The  mucous  patches 
and  tubercles  were  swept  lightly  over  with  the  solid 
argenti  nitras,  and  the  patient  was  put  on  the  usual 
mild  mercurial  treatment  with  an  extra  tonic.  Thus, 
(Mass.  Hyd.  2  grs.,  Ferri  Exsic  i  gr.,  and  pil.  quin.  bi- 
sulph.  2  grs.)  one  of  each  thrice  daily,  and  in  addition 
at  the  same  time,  a  teaspoonful  of  a  solution  (made  up 
fresh  daily)  of  the  sulphide  of  calcium  (2  grs.  to  2  i  of 
water).  Rest  in  bed  or  on  a  lounge  until  healing  of  the 
wound  of  operation  ;  simple  but  nutritious  diet.  On  the 
third  day,  when  the  stitches  were  removed,  healing  was 
found  to  be  complete.  Under  the  local  and  internal  treat- 
ment above  indicated,  touching  the  mucous  patches  and 
papular  daily  with  the  arg.  nit.,  this,  with  the  abstinence 
from  tobacco  to  which  the  patient  was  addicted  in  all 
forms,  resulted  in  prompt  improvement,  and  in  a  short 
time  the  open  lesions  had  entirely  healed  and  returned 
to  their  original  papular  condition,  and  the  sulphide  of 
calcium  was  dropped.  Through  the  indifference  and 
want  of  sense  in  the  patient  the  continuation  of  the  mer- 
curial and  tonic  treatment  was  very  irregular,  and  its 
effect  was,  moreover,  much  depreciated  by  occasional 
excesses  in  alcoholic  stimulants  and  tobacco.  While 
there  was  no  return  of  ulceration  in  the  papules,  an 


120  PRACTICAL  CLINICAL  LESSONS  ON 

ulceration  involving  both  tonsils  occurred,  requiring 
local  treatment  (application  of  acid  nit.  fort,  at  first,  then 
soHd  argent,  nit.)  for  several  weeks,  and  finally  healing, 
leaving  the  whole  pharynx  congested,  and  at  times 
quite  sensitive.  A  saturated  watery  solution  of  the  chlo- 
rate of  potassa  had  been  in  daily  use  as  a  gargle  and 
mouth-wash  from  the  commencement  of  the  mercurial 
course  (as  is  usual  in  such  cases),  and  was  continued 
with  occasional  applications  of  a  strong  solution  of 
tannin  and  glycerine,  when  the  sensitiveness  of  the 
gums  became  manifest.  The  mercurial  treatment  was 
kept  up  more  or  less  regularly,  as  originally  com- 
menced, for  about  a  year,  only  twice  or  thrice  result- 
ing in  any  perceptible  effect  on  the  gums.  The  papu- 
lar eruption  passed  off  the  body,  quite  losing  the  sali- 
ence within  two  or  three  months ;  but  on  the  thighs, 
wherever  a  pustulation  had  occurred,  a  faint  coppery 
stain  was  discernible  at  the  year's  end,  and  on  the 
legs,  where  the  ulceration  was  most  marked,  the  stain 
was  at  that  time  of  a  deep  coppery  hue.  The  throat  was 
no  longer  habitually  congested,  but  still  it  was  more 
easily  affected  by  changes  of  weather  than  formerly, 
and  the  occasional  necessity  for  his  gargle  was  recog- 
nized. The  general  health  of  patient  had  not  suffered 
during  this  long  period  of  medication.  He  had  become 
steadier  in  his  ways,  and  had  been  for  some  time  per- 
fectly regular  in  his  treatment.  The  gland  enlargements 
at  all  points  were  greatly  decreased,  but  still  readily  dis- 
cernible. Of  the  initial  lesion  there  was  not  a  trace. 
Even  the  Hne  of  union  of  the  cut  surfaces  was  scarcely 
to  be  distinguished  from  the  natural  creases  or  wrinkles 
in  this  localit}^  and  there  was  absolutely  no  more  evi- 
dence of  loss  of  tissue  than  if  a  simple  foreign  body  had 
been  removed.  The  patient  now  wishing  to  change 
his  residence  to  a  distant  part  of  the  country,  desired 
specific  instructions  as  to  the  length  of  time  he  still 
required  to  continue  treatment,  and  what  changes,  if 
any,  were  to  be  made. 

He  was  informed  that  the  present  treatment,  or  its 
equivalent,  should  be  pursued  for  still  another  year, 
always  in  such  degree  as  not  to  affect  the  general  health 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.    121 

unfavorably.  Alternating  it  from  time  to  time  with  the 
iodide  of  potassium  (5  or  6  grs.,  three  times  a  day),  or 
taking  that  drug  in  combination  with  it — (Mist.  Binio- 
did.  Hydrarg.)  He  desired  still  further  to  inquire  as  to 
whether  or  not  he  was  still  capable  of  communicating 
the  disease  through  ordinary  contact,  or  otherwise,  and, 
if  so,  when  he  would  probably  be  free  from  such  danger. 

In  response  to  this  he  was  informed  that,  although 
he  had  no  open  lesion,  the  contagious  element  of  the 
disease  was  doubtless  still  in  his  system,  and  that  the 
complete  disappearance  of  the  material  evidences  of  the 
disease,  which  included  gland  enlargements,  at  all  points, 
would  be  necessary  before  the  incapacity  to  commu- 
nicate the  disease  could  be  reasonably  claimed.  That 
this,  in  a  case  like  his,  where  early  treatment  had  been 
neglected,  and  he  had  suffered  from  some  of  the  severer 
lesions  of  the  disease,  immu7iity  from  danger  of  comniunu 
catirig  syphilis  could  not  confidently  be  expected  in  less  than 
from  two  to  three  years  from  the  date  of  its  acquirement. 

That  while  lesions  of  syphilis  certainly  recognized  as 
containing  a  contagious  element,  such  as  the  true  mu- 
cous patch,  papule,  or  tubercle,  were  rarely,  if  ever  seen, 
after  the  first  year,  but  if  the  contagious  element  Avas 
still  in  the  system,  it  might  escape  through  an  ordinary 
abrasion,  or  wound,  or  sore,  of  any  description,  and,  if 
brought  in  contact  with  a  fracture  of  skin  or  mucous 
membrane  on  a  healthy  person,  it  would  communicate 
syphilis.  Thus  sexual  contact  was  not  without  dan- 
ger of  communicating  syphilis  in  such  cases,  even  when 
no  recognized  syphilitic  le.sion  was  present  at  any 
point. 

Again,  lastly,  he  desired  to  be  informed  as  to  whether 
or  not  he  would,  as  a  conscientious  and  upright  man, 
be  justified  in  looking  forward  to  marriage  within  the 
next  five  years. 

This  question,  virtually  identical  with  the  previous 
one,  yet  embracing  the  assumption  of  a  responsibility 
which,  if  assumed  prematurely  or  in  error,  might  inflict 
irreparable  evil  on  a  future  wife  and  offspring,  could 
only  be  fully  answered  after  the  probationary  period  of  c^ 
year  subsequent  to  the  cessation  of  the  treatment. 


122  PRACTICAL   CLINICAL   LESSONS   ON 

Provisionally,  it  might  be  stated  that,  after  the  pur- 
suance of  a  judicious,  thorough,  and  well-borne  mercu- 
rial course  for  at  least  one  and  a  half  to  two  years,  and  as 
long  after  (up  to  three  years)  as  necessary  to  secure  the 
complete  disappearance  of  all  gland  enlargements  due  to 
syphilis  aud  all  other  evidences  of  the  activity  of  the  disease 
then  if,  for  the  full  period  of  one  more  year,  on  care- 
ful scrutiny  no  evidence  of  the  disease  was  manifest, 
consent  to  marriage  would  be  justifiable  as  far  as  the 
question  of  conununicatioji  of  syphilis  was  concerned. 
But  every  person  who  has  once  suffered  from  syphilis, 
no  matter  in  how  light  or  how  transient  a  form,  is  liable 
to  suffer  from  trouble  in  various  forms,  known  as  the 
SequelcB  of  Syphilis.  The  earlier  and  more  thorough  the 
treatment  the  less  the  liability  to  these  troubles.  They 
might  be  very  slight  and  pass  off  without  recognition 
even,  or  be  so  grave  as  to  threaten  life.  Such  troubles, 
usually  spoken  of  as  Tertiary  Syphilitic  lesions,  con- 
stituted a  purely  personal  matter  in  every  case,  wholly 
lacking  the  contagious  element.  They  are  not  a  neces- 
sary part  of  syphilis,  and,  when  occurring  and  recog- 
nized early,  they  are  eminently  amenable  to  treatment. 
As  before  stated,  those  cases  of  syphilis  early,  thor- 
oughly, and  wisely  treated,  during  the  active  period 
of  the  disease,  escape  as  the  rule.  Yet  every  one 
once  the  subject  of  syphilis  should  never  forget  the 
possibility  of  such  accident,  and,  whenever  suffering 
from  any  serious  or  unusual  difficulty,  should  always 
communicate  the  fact  to  the  medical  attendant  in  charge 
of  the  case. 

Remarks. — The  foregoing  case  presents  a  good  exam- 
ple of  the  causes  and  conditions  which  determine  pustu- 
lation  and  ulceration  in  the  papular  eruptions  of  syphilis. 

1.  The  debilitated  condition  of  the  patient  favoring 
the  suppurative  process. 

2.  The  character  of  his  business  requiring  many  hours 
daily  in  a  standing  position,  producing  additional  ten- 
dency to  congestion  in  the  papules  of  the  lower  extremi- 
ties, and  this  increasing  the  suppurative  action,  result- 
ing in  the  ulcers  about  the  legs  and  ankles  ;  papules  also 
becoming  mucous  patches  and  ulcers  in  moist  places. 


SYPHILIS   AND   THE   GENITO-URINARY  DISEASES.    1 23 

Consideration  of  the  causes  which  may  affect  any  pre- 
senting eruption  of  syphilis  from  condition,  locality,  and 
business,  etc.,  will  suggest  judicious  modifications  in  the 
hygienic  as  well  as  the  medicinal  treatment,  and  make 
us  hesitate  in  classifying  eruptions  of  identical  origin  in 
a  manner  tending  to  obscure  the  real  causes  of  differ- 
ence in  appearance  and  amenability  to  treatment. 


124  PRACTICAL  CLINICAL  LESSONS   ON 


LESSON  XVI. 

Length  of  time  required  for  complete  cure  of  Syphilis  variable  :  gentle, 
steady  influence  of  mercury  from  one  and  a  half  to  three  years — Popu- 
lar prejudice  against  mercury  not  well  grounded — Testimony  of  all 
authorities  in  its  favor — Destructive  lesions  of  Syphilis  belong  to  the 
late  stage — Treatment  not  addressed  chiefly  to  the  accidents  of  the 
active  stage,  but  to  the  prevention  of  so-called  Tertiary  accidents — The 
Sequelae  of  Syphilis — Unwarranted  responsibility  taken  by  those  who 
claim  safety  after  a  brief  period  of  treatment — Light  form  of  early 
Syphilis  no  guarantee  against  grave  late  lesions — M,  Fournier's  views 
— Prolonged  and  judicious  administration  of  mercury  essential  in  every 
case  of  Syphilis — Exceptions  where  treatment  is  not  well  borne  very 
few — Security  against  late  troubles  to  be  effected  in  no  other  way. 

General  remarks. — The  length  of  time  usually  required 
for  the  complete  cure  of  syphilis  will  vary  in  different 
individuals  from  one  and  a  half  to  three  years,  and  dur- 
ing all  this  time  the  steady,  gentle  influence  of  the  mer- 
curial in  form,  dose,  and  mode  of  administration  as  pre- 
viously stated  (page  119)  is  required  until  all  abnormal 
cell-accumulations  dependent  upon  the  syphilitic  influ- 
ence have  disappeared.  When  after  a  year  and  a  half  to 
two  years  all  external  evidences  of  the  disease  have  passed 
away,  and  the  ly^nphatic  glands  can  no  lo7iger  be  felt,  or  have 
returned  to  the  condition  in  which  they  were  found  pre- 
vious to  the  constitutional  stage  of  the  disease,  the  treat- 
ment may  be  discontinued,  but  not  before,  unless  there  is 
some  idiosyncrasy  in  the  patie^it  which  contra-indicates  its 
use.  If  the  patients  are  faithful,  sensible,  and  obedient, 
in  by  far  the  largest  majority  of  cases,  they  will  pass 
through  the  trouble  easily  and  happily  to  a  complete 
cure.  A  great  weight  of  experience  in  the  plan  of 
treatment  which  I  have  indicated  (including  that  of  the 
most  distinguished  authorities  in  Europe  and  America), 
assures  us  of  the  truth  of  this,  and  the  patients  do  not 
suffer  from  the  long-continued  treatment  in  any  appre- 
ciable way,  and  that  in  consequence  of  it  they  have  the 
greatest  and  the  only  security  of  escape  from  the  so- 
palled  tertiary,  or  late  lesions — the  sequelae  of  syphilis, 


SYPHILIS   AND   THE   GENITO-URINARY  DISEASES,    12$ 

I  am  quite  aware  that  there  is  a  great  popular  preju- 
dice against  the  use  of  mercury  in  syphilis,  and  this  has 
arisen  in  great  measure  from  the  abuse  of  the  drug  in 
earlier  times,  but  it  has  been  kept  up  and  intensified  by 
quacks  and  the  ignorant  and  the  unworthy  of  our  pro- 
fession, who,  from  causes  and  motives  natural  to  these 
classes,  refuse  to  accept  the  testimony  of  the  learned 
and  experienced  authorities,  who  are  now  in  complete 
accord  in  this  matter,  in  every  part  of  the  world.  With- 
out a  show  of  evidence,  or  experience,  entitled  to  respect, 
they  deny  the  necessity  of  the  mercurial  treatment,  and 
make  the  pretence,  that  syphilis  may  be  as  efficiently,  and 
more  safely,  managed  without  it.  They  point  to  cases 
thus  treated,  apparently  well  of  the  disease,  and  claim 
them,  as  evidences  of  the  truth  of  their  statements.  The 
very  important  fact,  that  syphilis,  in  its  acute  period,  is 
a  self-limited  disease,  and  will  pass  away  with  any  sort 
of  treatment,  or  without  treatment,  is  not  made  appar- 
ent. This  is  the  fact,  and  while  we  claim  and  know, 
that  a  judicious  mercurial  treatment,  will  hasten  the  cure 
of  the  active  lesions  and  stages  of  syphilis,  it  is  not  on 
this  account,  that  the  treatment  is  considered  essentiaL 
It  is  because,  more  than  any  other  known  remedy,  it 
prevents  the  sequelae  of  syphilis — the  so-called  tertiary 
and  quarternary  lesions — which  result  in  destruction  of 
important  tissues  and  organs,  vessels  and  bones.  These 
accidents  do  not  occur  in  the  early  or  acute  stages  of  syphilis. 
After  the  apparent  disappearance  of  syphilis,  in  a  few 
months,  or  a  year  or  so,  there  comes  a  deceitful  period 
of  perfect  health,  perhaps.  The  disease  is  perhaps 
cured  ;  but  in  two,  or  three,  or  ten,  or  twenty  years  after, 
new  trouble  may  arise,  no  longer  contagious,  as  in  the 
past  syphilis,  but  destructive.  It  is  this,  that  causes  the 
really  important  damage.  Deformity,  disability  of  body 
or  brain,  or  both,  and,  finally,  in  some  cases,  death.  It 
is  to  avoid  the  danger,  present  in  every  case  of  syphilis, 
of  such  results,  that  the  persistent  and  judicious  use  of 
mercury  during  the  acute  period  of  the  disease  is  most 
important,  and  is,  as  we  fully  believe  and  know,  abso- 
lutely essential.  We  do  not  urge  the  administration  of 
mercurials,  without  a  due  consideration  of  the  respon- 


126  PRACTICAL  CLINICAL  LESSONS  ON 

sibility  we  take  in  so  doing,  without  a  knowledge  of  all 
it  has  ever  done,  that  is  objectionable,  or  ever  may  do. 
It  is  because,  without  a  systematic,  judicious  mercu- 
rial course,  the  patient  who  has  once  been  a  subject  of 
syphilis,  in  no  matter  how  light  a  form,  or  how  shghtor 
short-lived  the  manifestation,  is  in  jeopardy  every  hour, 
and  that  nothing  but  a  course  of  simple  mercurial  treat- 
ment, continued  systematically  for  at  least  a  year,  can 
afford  any  reliable  security.  This  is  the  experience  of 
all  in  our  profession  who  have  any  title  to  a  respectful 
hearing,  on  account  of  wisdom  and  experience,  and  in 
the  present  state  of  our  knowledge  of  this  matter  it  is 
sufficient  to  warrant  you  in  insisting  upon  the  necessity 
of  such  a  course  of  treatment  in  every  case  of  syphilis 
which  in  the  future  may  present  to  you  for  care  and 
treatment.* 

Do  not  understand  me  to  say  that  every  case  shall  be 
treated  in  the  same  manner,  as  to  the  size  of  the  dose  or 
the  mode  of  administration,  and  without  regard  to  the 
physical  condition  and  circumstances.  A  judicious  fol- 
lowing of  the  plan  insisted  on  is  necessary,  i.e.,  such  an 
amount  and  such  a  mode  of  administration  as  may  be 
borne  without  disturbing  the  digestive  apparatus,  or 
materially  interfering  with  the  processes  of  nutrition. 
As  a  rule,  if  the  medicine  is  judiciously  administered, 
the  patient  will  not  only  not  be  disturbed,  but  he  will 
improve  in  both  these  respects.  How  much  a  more 
regular  and  exemplary  mode  of  life,  which  a  proper 
management  of  syphilis  necessitates,  has  to  do  with  the 
improved  condition,  I  am  not  able  exactly  to  state,  but 
it  is  nevertheless  a  fact,  that  most  young  men  are  in 

*  The  distinguished  French  syphilographer,  M.  Fournier,  says  on  this 
point:  "  Experience  teaches  us  that  syphilis,  originally  mild,  may  reveal 
itself  sooner  or  later  in  serious  symptoms,  if  it  has  not  been  submitted, 
like  the  more  malignant  forms,  to  a  prolonged  and  severe  treatment. 
One  has  seen,  more  than  once,  syphilis  of  this  kind,  negligently  treated 
by  reason  of  its  apparent  benignity,  become,  later,  singularly  dangerous 
in  marriage  in  the  double  possibility  of  contagion  and  heredity.  ...  It 
is  to-day  proved,  that  the  initial  benignity  of  syphilis  does  not  constitute 
in  any  degree  an  absolute  guarantee  for  the  future.  Such  syphilis  which 
begins  well,  is  not,  for  that  reason,  unexposed  toabad  end."  ("Syphilis 
and  Marriage,"  by  M.  Alfred  Fournier.     London  Ed.  1881,  pp.  ill,  112.) 


SYPHILIS  AND   THE   GENITO-URINARY  DISEASES,    I^; 

better  health,  after  a  judicious  course  of  specific  treat- 
ment for  syphilis,  than  before  its  acquirement. 

1  do  not  wish  to  be  understood  that  no  other  medi- 
cines are  necessary,  or  advisable,  in  any  case  of  active 
syphilis.  There  are  idiosyncrasies  that  must  be  re- 
spected— cases  that  will  not  bear  the  ordinary  amount 
of  mercurial  without  trouble  of  some  sort.  These  are 
fortunately  rare;  but  when  they  present,  vou  must  use 
your  ingenuity,  so  to  select  the  particular  form,  and  com- 
bine your  most  excellent  remedy,  that  it  may  be  borne. 
You  may  alternate  it  with  the  iodide  of  potassiumi, 
which  is  also  an  agent  of  much  value  in  bringing  about 
fatty  degeneration  of  living  tissue,  or  you  may,  if  you 
can  do  better,  rely  upon  this  drug  in  combination  with 
other  means  and  measures  which  are  known  to  favor 
fatty  degeneration  and  elimination. 

You  are  likely  to  meet  with  cases  that  will  try  your 
temper  and  courage :  that  will  call  into  fullest  requisi- 
tion all  your  knowledge  and  your  experience  and  your 
judgment,  and,  not  least,  all  your  common  sense,  and 
yet  fail  to  obtain  such  a  toleration  of  the  mercurial  as 
will  enable  you  to  prevent  the  occurrence  of  the  sequelas 
of  syphilis.  These  cases  will,  however,  I  am  glad  to 
say  to  you,  be  rare  exceptions,  and  you  may  have  the 
assurance  of  the  rule,  that  such  a  plan  of  treatmentas 
I  have  sketched  out  for  you  will  be  well  borne,  and  will 
not  alone  aid  you,  in  carrying  your  patient  with  com- 
parative equanimity  and  comfort,  through  the  acute 
stages  of  this  disease,  but,  what  is  of  infinitely  greater 
importance,  you  will  give  him,  the  greatest  possible  se- 
curity, against  an  occurrence  of  the  seqiielce  or  manifes- 
tations of  so-called  chronic  or  tertiary  syphilis. 


128  PRACtlCAI    CLINICAL    LESSONS  OK 


LESSON  XVIL 

Resume  showing  that  the  contagious  property  of  sj^philis  is  not  an  in- 
dependent virus  pervading  all  tissues,  but  is  confined  to  tne  white  blood, 
or  tissue-building  cells,  and  that  the  only  peculiarity  of  such  cells  is 
a  contagious  influence  which  is  not  distinguishable  by  microscopical 
examination.  That  its  effect  is  to  induce  hasty  proliferation  of  cell 
material,  and  that  the  result  of  this  is  not  primarily  destructive,  but 
causes  disturbance  through  mechanical  interference  with  processes  of 
nutrition.  The  property  of  contagion,  inherent  in  normal  cell  develop- 
ment; all  troubles  occurring  after  the  contagious  period  of  syphilis, 
which  clinical  observation  has  shown  to  be  limited — necessarily  con- 
sidered as  0^^7/1?/^.  Mr.  Hutchinson's  views  on  this  point;  the  views  of 
Mr.  Henry  Lee  and  Mr.  Lane.  The  tubercular  QxVi\^\\ox\  the  first  sequel 
of  syphilis.  lis  characteristics  and  behavior.  Syphilitic  ecthyma; 
syphilitic  rupia;  no  specific  element  in  their  composition.  The  lepra 
and  psoriasis  of  ryphilis  not  distinguishable  from,  the  simple  forms  ex- 
cept through  effects  of  treatment,  all  caused  by  interference  with  natu- 
ral functions  of  tissues.  Evidences  of  this  interference  confined  to  the 
lymphatic  channels.  This  view  supported  by  Rindfleisch,  also  by 
effects  of  treatment,  all  alike  requiring  mercury  and  the  iodide  of  potas- 
sium. Proposal  to  substitute  the  term  Period  of  Lymphatic  Obstruc- 
tion for  the  old  terms,  Tertiary  and  Quarternary  Syphilis^  Reasons 
for  claiming  that  this  syphilitic  obstruction  is  due  to  damage  to  lymph 
channels  during  the  active  period  of  syphilis. 


THE    SEQUELS    OF   SYPHILIS. 

Syn.:  Chronic  or  Late  Syphilis,  Tertiary  and  Quater- 
nary Syphilis. — In  following  the  natural  history  of  S)^ph- 
ilis,  as  portrayed  in  the  preceding  pages,  it  will  be 
seen,  that,  wherever  the  s}- philitic  influence  is  recognized 
at  a  given  point,  culminating  in  a  well-marked  mani- 
festation of  syphilis,  this,  on  microscopic  examination, 
has  been  found  to  differ  from  the  health}'  surrounding 
structures,  only  by  an  excessive  local  proliferation  and 
accumulation  of  cells,  in  no  way  distinguishable  from 
normal  germinal  cells.  It  will  also  be  seen  that  this  local 
proliferation  and  accumulation,  is  favored  by  anatom- 
ical conditions,  in  localities  long  recognized,  clinically, 
as  the  favorite  seat  of  such  manifestations. 

The  active  period  of  syphihs,  thus  marked  by  exces- 
sive localized  cell  proliferation,  was  shown  to  be  equally 
characterized  by  the  contagious  property  attaching  to 


SYPHILIS  AND   THE   GENITO-URINARY   DISEASES.    1 29 

cells  thus  generated.  Inoculation  of  the  blood,  and  of 
the  secretion  of  all  open  lesions,  during  the  active  period 
of  syphilis,  has  been  found  capable  of  communicating 
syphilis  promptly^  to  healthy  persons. 

The  physiological  secretions — milk,  saliva,  mucous, 
urine,  perspiration,  tears,  and  the  spermatic  fluid — have 
not  been  proven  to  be  agents  of  syphilitic  infection. 
Where  apparently  so,  in  many  cases,  syphilitic  lesions  of 
the  mouth  or  breast  have  been  found,  to  account  for  the 
seeming  inoculability  of  the  saliva  or  of  the  milk.  Re- 
peated experiments  have  been  made  by  inoculation  of 
the  spermatic  fluid  of  a  person  proven  to  be  in  the  active 
stage  of  syphihs,  upon  healthy  persons,  with  absolutely 
negative  results.^  In  this  we  find  confirmation  of  our 
position,  that  the  contagious  property  of  syphilis  is  not 
an  entity,  an  independent  virus,  pervading  all  the  tissues 
and  fluids  of  the  organism,  but  that  it  is  confined  to  the 
white  blood  or  tissue-building  cells.  In  this  view  of 
the  matter  we  readily  see  how  the  physiological  secre- 
tions above  mentioned,  which  do  not  contain  formative 
cells,  are  found  also  to  be  free  from  the  contagious 
property  of  syphilis. 

Thus  far,  the  only  distinguishing  feature  which  has 
been  recognized,  between  normal  embryonal  cells,  and 
cells  which  make  up  the  accumulations  characteristic  of 
the  active  stage  of  syphilis,  is  the  possession,  by  the  lat- 
ter, of  the  contagious  property.  In  other  words,  a  con- 
tagitim  :  the  power  of  setting  up  in  other  cells,  through 
simple  contact,  the  same  disposition  to  rapid  prolifera- 
tion, which  the  so-called  syphilitic  cells  are  known  to 
possess.  The  direct  result  of  this  hasty  proliferation,  as 
far  as  we  have  yet  been  able  to  discover,  is  not  a  de- 
structive action.  It  is,  simply  and  only,  what  we  should 
naturally  expect  from  hastily  generated  normal  material, 
in  excess  of  the  necessities  of  growth  and  repair.  In 
representative,  uncomplicated  cases,  it  remains  for  a 
time,  obstructing  the  tissues  by  its  presence,  and  then 
through  purely  normal  processes,  (often  of  necessity  set 

*  Dr.  Mireur,  of  Marseilles.     Annales  de  Dermatologie  et  de  Syphilo* 
graphic,  No,  6,  tome  viii,     1877. 


130  PRACTICAL  CLINICAL   LESSONS   ON 

into  operation  by  crowding  of  the  newly-formed  cells, 
prolonged  pressure,  and  consequent  innutrition,  and  also, 
from  general  causes),  it  undergoes  fatty  degeneration, 
and  is  in  this  way  finally  eliminated  from  the  affected 
organism.^ 

Baumler  virtually  supports  this  viewf  when  he  says 
of  the  active  stage  of  syphilis,  "  If  there  are  only  a  few 
local  deposits,  the  elimination  of  the  virus  may  be  so 
much  in  excess  of  its  production  that  the  organism  is 
gradually  freed  from  it.  This  takes  place  in  the  majority 
of  cases,  and,  at  the  expiration  of  eighteen  months  or  two 
years,  the  infection  is  entirely  exhaiistedr 

Mr.  Hutchinson,  of  London,  in  speaking  of  the  con- 
tagious propert}^  which  attaches  to  the  emasculated 
white  blood  cell,  which  we  call  pus,  says,  ''  All  living 
pus  is  contagious.  ...  I  mean,"  he  further  says, 
"that  all  pus  cells  possess  the  power  of  setting  up, 
when  transferred  to  another  home,  if  that  home  be  a 
suitable  one,  a  kind  of  inflammatory  action  similar  to 
that  from  whence  they  themselves  had  originated."  J 
This,  we  know,  results  in  the  almost  immediate  death 
of  cells  in  localities  so  contaminated.  In  the  case  of 
the  germinal  cells,  contaminated  by  contact  with  the 
syphilitic  cells,  however,  this  results  in  a  hasty  genesis 
of  cells,  a  too  rapid  production,  which  prevents  their 
highest  development ;  they  fall  by  the  way,  are  heaped 
up,  undergo  fatty  degeneration,  and  are,  or  may  be, 
eliminated.  Nor  is  it  alone  in  diseased  cells  that  a  con- 
tagious property  is  claimed  to  reside.  We  have  dis- 
tinguished authority  for  saying  that,  in  the  normal  de- 
velopment of  epithelial  structures,  the  property  of 
contagion  is  an  essential  feature. §  If  this  be  true,  it  at 
once  becomes  evident  that  the  contagious  property  is 
not  of  necessity  a  virus ;  and  it  must,  I  think,  be  sug- 
gested, in  this  view  of  the  matter,  as  equally  evident, 

*  A  fatty  metamorphosis,  entirely  like  that  which  occurs  pathologically, 
occurs  in  the  normal  condition  of  the  organism.     Wagner,  p.  305. 

f  P.  247  of  Ziemssen's  Cyclopaedia,  Am.  ed. ,  vol.  iii. 

%Lo7ido7i  Lancet,  September  18,  1875,  p.  409. 

§  Text-Book  of  Pathological  Histology.  Rindfleisch.  Am.  ed..  1871, 
p.  100,  §  83. 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES,    I3I 

that  the  so-called  virus  of  syphilis  is  simply  the  manifest- 
ation of  a  property  or  personal  influence,  inherent  in 
all  cells,  whether  healthy  or  degraded,  and  which  is  as 
subtle  and  intangible,  as  incapable  of  material  dem- 
onstration, as  the  influence  which  one  mind  exerts 
over  another.  Is  it  not  then  possible,  that  the  mischief 
which  syphilis  does,  is  rather  the  result  of  an  interfer- 
ence with  the  normal  processes,  through  hasty  develop- 
ment, brought  about  by  this  influence,  than  of  the  action 
of  a  specific  virus  ? 

In  any  event  this  contagious  property  of  syphilis 
ceases  with  the  active  period  of  the  disease.  After 
this  has  passed,  the  secretions  of  open  lesions,  and  the 
blood,  no  longer  contaminate.  It  may  also  be  said,  that, 
in  by  far  the  greater  number  of  subjects  of  syphilis, 
(and  more  especially  those  who  have  been  systemati- 
cally and  judiciously  treated),  they  remain  free  from  any 
farther  sign  of  the  disease.  If  this  be  so,  then  we  may 
legitimately  claim,  that,  at  the  termination  of  the  active 
period  of  syphilis,  just  described,  all  subsequent  troubles 
must  be  looked  upon  as  seqiielce,  and  not  as  a  stage  of 
syphilis,  any  more  than  we  should  look  upon  dropsy 
as  a  stage  of  scarlet  fever,  or  stricture  as  a  stage  of 
gonorrhoea.  Mr.  Hutchinson,  who  is  recognized  as 
one  of  the  most  advanced  of  the  English  authorities  on 
syphilis,  says  :  "  What  are  called  tertiary  symptoms,  do 
not  constitute  a  necessary  stage,  and  are" rather  to  be 
regarded  in  the  light  of  seqiielce,  which  may  or  may 
not  show  themselves."  *  Mr.  Henry  Lee  (also  a  valued 
authority),  in  his  Hunterian  Lectures,  delivered  at  the 
Royal  College  of  Surgeons  of  England  in  1875,  pre- 
sents the  same  view  of  so-called  tertiary  or  late  syphilis, 
thus  :  "  The  pathological  changes  in  this  class,  occasion- 
ally, according  to  Mr.  Lane's  view,  present  themselves 
in  patients,  who  have  passed  through  the  primary  and 
secondary  stages  of  syphilis,  but  in  whom  the  venereal 
poison  no  longer  exists,  and  therefore  cannot  be  traiis- 
mittedy 

This  is,  I  know,  quite  at  variance  with   the   usual 

*  London  Lancet,  p.  83,  January  17,  1874. 


132  PRACTICAL  CLINICAL  LESSONS  ON 

teaching  in  this  matter.  The  accidents  following  upon 
the  active  period  of  syphilis  are  usually  representedj 
not  as  sequelse,  but  as  the  direct  result  of  the  syphi- 
litic virus,  which  had  never  been  completely  elimi- 
nated, but  had  remained  in  the  system  in  a  latent  state. 
Authorities  are  quite  agreed,  however,  in  regard  to 
the  clinical  fact,  that,  after  a  varying  interval,  of  from 
one  to  forty  or  fifty  years  from  the  acquirement  of 
sj'philis,  a  new  variety  of  lesions  appears  in  certain 
cases. 

These  are  often  characteristic,  although  widely  dif- 
ferent in  localit}^,  appearance,  and  results.  Occurring 
only  in  a  small  proportion  of  the  subjects  of  active  syph- 
ilis, they  are  thus  shown,  not  to  constitute  an  essential 
stage  of  the  disease,  but  the  accident  of  it.  Thus  the 
so-called  tubercular  eruption,  like  the  papular  eruption  of 
acute  S3'philis,  in  some  respects,  is  often  mistaken  for 
it,  but  differing,  in  that 

ist,  it  never  "^  occurs  in  less  than  six  months,  and 
rarely  under  a  year,  from  the  acquirement  of  the  initial 
lesion  ; 

2d,  it  is  not  symmetrical  and  generally  distributed, 
but  in  patches,  or  groups,  or  single  tubercles, 

*  I  am  aware  that  ulcerati\'e  lesions  occur,  though  rarely,  at  the  usual 
period  for  the  papular  eruption,  that  are  accepted  by  some  authorities  as 
belonging  to  the  later  stages  of  the  disease.  I  think,  however,  in  all 
such  cases,  that  the  possible  behavior  of  a  papule  or  a  lesion,  resulting 
from  the  peculiar  condition  of  the  subject,  will  be  sufficient  to  explain 
the  nature  of  the  accident  without  referring  it  to  the  so-called  "  tertiary 
stage;"  or,  if  not,  it  will  be  found  that  the  patient  has  had  a  previous  at- 
tack of  syphilis  at  a  period  sufficiently  remote  to  account  legitimately  for 
the  appearance  of  a  tertiary  lesion.  The  tubercle  or  its  equivalent,  viz., 
an  accumulation  of  so-called  ^z^w/«jj/ or  germinal  material,  which  is  the 
result  of  a  necessary  previous  stage,  and  lacks  the  contagious  element, 
is  the  first  of  the  accidents  of  the  so-called  tertiary  stage — the  sequel 
of  syphilis.  Notwithstanding  that  M.  Cornil,  in  his  recent^xcellent  work 
on  syphilis  (p.  204),  states  that,  "  In  the  tubercles  and  gummata  of  the 
skin  are  seen  the  latest  and  deepest  manifestations  of  cutaneous  syphilis," 
yet  he  also  states  (p.  215)  that  "the  very  first  symptoms  of  syphilis 
may  be  deep-generalized  pustular  or  ulcerating  eruptions,"  identical  with 
those  coming  on  after  a  period  of  many  years  (the  seqiielce),  ""following 
immediately  after  the  chancre." — Cornil  on  Syphilis.  Am.  ed.,  Phila., 
1882.  I  do  not  hesitate  to  claim  that  such  cases,  wherecritically  analyzed, 
will  be  found  to  be  as  rare,  as  where,  in  nature,  fruit  has  the  precedence 
of  the  blossom.— F.  N.  O. 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.      1 33 

3d,  of  deeper  color,  it  is  also  more  elevated — more 
juicy  in  appearance, 

4th,  while  frequently  ulcerating  (and  often  extensively), 
it  not  unfrequently  passes  off  without  ulceration,  and  yet 
leaving-  well-marked  cicatricial  depressions  on  its  site. 
This  latter  is  the  chief  diagnostic  point,  independent  of 
history  or  other  associated  lesion,  of  the  tubercular 
eruption  of  syphilis.  In  other  cases,  under  apparently 
the  same  conditions,  an  eruption,  sero-pustular  in  charac- 
ter, may  occur,  the  eruptive  points  varying  from  three 
to  six  or  more  millimetres  in  diameter,  often  sparsely 
scattered  over  the  entire  body,  which  soon  become  cov- 
ered with  thick  yellow  laminated  incrustations,  and 
these,  when  removed,  discover  only  superficial  loss  of 
integument.  This  is  known  as  the  SypJiilitic  Ecthyma. 
And  again,  in  still  other  individuals,  one  or  many  red 
spots  may  appear,  which  soon  vesiculate  and  be- 
come covered  with  a  dark  sienna-colored  scab,  which 
accumulates  in  layers,  and  increasing  in  size,  may 
reach  even  an  inch  or  more  in  diameter,  upon  the  re- 
moval of  which  sharply  cut  loss  of  tissue  will  be  seen, 
not  seldom  involving  the  entire  thickness  of  the  integu- 
ment. This  is  termed  by  authors  the  Syphilitic  Ritpia. 
Examination  of  all  these  lesions  fails  to  discover  any 
specific  material  or  element  in  their  composition.  The 
microscope  shows  chiefly  serum,  lymph  and  pus  cells, 
blood  and  epithehal  debris.  A  depreciated  condition 
of  the  general  system,  is  alwaj^s  the  precursor  of  such 
symptoms,  especially  marked  in  the  rupetic  variety. 
And  yet  again,  eruptions  may  occur  presenting  appear- 
ances similar  to  simple  lepra,  or  psoriasis,  or  eczema, 
oftentimes  so  nearly  identical  in  appearance  that  only 
the  test  of  treatment  enables  even  the  expert  derma- 
tologist to  decide  as  to  whether  the  disease  is  of  simple 
or  of  syphilitic  origin.  Underneath  the  integument 
tumors  sometimes  occur,  varying  in  size  from  a  pea  to 
a  pullet's  Qg^,  in  the  cellular  tissue,  or  in  the  sub- 
stance of  the  muscular  structures  ;  often  painless,  seldom 
suppurating,  except  when  subjected  to  prolonged  and 
habitual  pressure,  often  disappearing  spontaneously  and 
readily  responding  to  suitable  treatment.     Tumors  ia 


134  PRACTICAL   CLINICAL   LESSONS   ON 

the  bones,  called  syphilitic  nodes,  are  also  possible,  oc- 
curring, like  the  previously  described  lesions  of  the  cu- 
taneous, cellular,  and  muscular  structures,  from  accu- 
mulation of  the  so-called  gummy  material,  at  any  time 
after  a  year  or  more  from  the  occurrence  of  acute 
syphilis,  and  up  to  the  latest  years  of  life ;  painless  or 
painful  according  as  the  periosteum  is  more  or  less 
rapidly  distended  or  pressed  upon  by  overlying  tissues. 
Chiefly  occurring  on  the  anterior  surface  of  the  long 
bones,  especially  of  the  tibiae,  and  on  the  external  tables 
of  the  skull,  occasionally  involving  the  internal  table  and 
the  diploe,  and  in  such  case  sometimes  disappearing  spon- 
taneously without  involving  the  scalp,  and  without  a 
trace  of  necrosis,  but  leaving  distinct  evidences  of  loss  of 
bony  substance  through  the  influence  of  pressure  b}^  the 
material  cause,  the  tumor.  Similar  tumors  of  bone  may 
occur  at  any  point  throughout  the  bony  system,  pro- 
ducing disturbance  by  pressure  on  important  structures. 
Tumors  in  the  various  organs  of  the  body,  occur 
apparently  from  similar  causes,  and  in  the  same  irregu- 
lar way  in  point  of  time,  involving,  in  order  of  fre- 
quency, as  follows :  Testes,  liver,  kidneys,  brain,  lungs, 
heart,  etc.  In  some  cases  walls  of  the  blood-vessels  are 
found  infiltrated  with  the  same  material  of  which  thetu 
mors  of  syphilitic  origin  are  found  to  be  composed,  and 
become  obstructed,  as  in  the  brain,  often  causing  fatty 
degeneration  of  the  structures  to  Avhich  they  are  dis- 
tributed. In  some  cases,  cicatricial  bands  are  found  to 
develop  in  organs  the  subject  of  syphilitic  tumors,  and 
b}'  contraction  and  consequent  constriction,  destroy  the 
secreting  structures,  notably  seen  in  the  liver  and 
testes  of  subjects  suffering  from  the  later  effects  of  the 
syphilitic  influence  in  these  organs.  It  will  thus  be 
seen  that  the  diseased  conditions,  enumerated  as  char- 
acteristic of  chronic  syphilis  (the  tertiary  and  quater- 
nar}'  syphilis  of  Lancereaux  and  other  authors),  are 
essentially  different  from  true  or  acute  syphilis,  in  date 
of  appearance,  mode  and  locality  of  development,  and 
in  the  entire  absence  of  the  contagious  syphilitic  ele- 
ment. Microscopic  examinations  have  brought  to 
li^ht  the  very  important  and  interesting  fact,  that  all 


SYPHILIS   AND   THE    GENITO-URINARY   DISEASES.    1 35 

the  various  sequelse  of  syphilis,  are  characterized  by 
the  presence  of  a  peculiar  material,  which,  from  its 
physical  properties,  has  received  the  name  of  "  gummy 
material."  This  material  has  been  proven,  by  repeated 
and  exhaustive  microscopical  examinations,  to  be  made 
up  of  gelatinous  fluid,  containing  normal  cells  and 
nuclei,  which  do  not  differ  in  the  least  demonstrable  de- 
gree, from  the  white  blood  cells  and  nuclei  of  a  healthy 
person.  Wagner,  perhaps  the  most  recent  standard 
authority,  says  of  this  gummous  material  (which  he 
terms  syphiloma):  ''Microscopically  syphiloma  con- 
sists of  cells,  or  nuclei,  or  both  at  the  same  time,  so 
that  sometimes  the  former,  sometimes  the  latter,  exceed 
in  number.  Young  syphilomata,  as  well  as  the  periph- 
eral parts  of  the  older  ones,  contain  for  the  most 
part  only  nuclei,  or  nuclei  and  isolated  cells ;  the  older 
syphilomata,  not  yet  very  atrophic,  consist  for  the 
most  part  only  of  cells,  or  of  cells  with  few  nuclei. 
The  nuclei  offer  nothing  characteristic.  They  are  from 
o.oi  to  0.02  mm.,  large,  round  or  rounded,  or  somewhat 
angular,  and  contain  for  the  most  part  a  distinct  nucle- 
olus. The  cells  resemble  most  uninucleate  colorless 
blood  corpuscles ;  their  size  varies,  however,  some- 
times, between  0.0 1  and  0.03  mm.;  some  are  even  still 
larger."  *  Again  Wagner  (page  436)  says :  ''  The  in- 
fluence of  syphiloma,  on  the  organism,  depends  upon 
the  fact,  that  the  affected  portions  of  the  membrane  and 
parenchymata,  are  more  or  less  incapable  of  fuiiction ; 
dependent  partly  on  the  deposit  of  cells,  and  especially 
of  nuclei,  upon  compression  or  secondary  atrophy  of 
the  gland  cells,  nerve  fibres,  ganglion  cells,"  etc. 

Baumler,  who  fully  adopts  Wagner's  views,  says : 
''  From  the  fact  of  the  close  resemblance  of  the  cells 
which  pervade  the  tissues,  or  occur  in  the  form  of 
young  tissue  growths,  with  the  blood-corpuscles,  it 
is  evident  that,  however  much,  they  (authors)  may 
characterize  syphilitic  new  formations,  they  wholly 
lack  specific  microscopic  char  act  ersT  He  also  says : 
"■  Tumors  of  this  sort  (gummy),  varying  in  consistency, 

*  Wagner's  Manual  of  General  Pathology,  Am.  ed,,  1876,  p.  435. 


136  PRACTICAL   CLINICAL  LESSONS   ON 

may  develop  in  any  organ  in  consequence  of  syphilis; 
but  their  favorite  seats  are  in  the  subcutaneous  cellular 
tissue,  the  skin,  in  and  upon  the  bones,  the  liver,  the 
testicles,  the  brain,  the  kidneys,  and,  especially  in  chil- 
dren, the  lungs.  According  to  Wagner's  description," 
he  further  says,  "  they  present  the  appearance  of  a 
rayish-red,  soft,  homogeneous  mass,  either  without 
uid  contents  or  else  yielding  a  scanty  juicy-like  mucus. 
They  may  occur  as  infiltrations  of  microscopic  size 
scattered  throughout  the  parenchyma  of  an  organ  ;  and 
even  when  they  appear  as  sizable  tumors,  as  large  as  a 
walnut  or  larger,  they  are  not  encysted  nor  sharply 
defined,  but  merge  directly  into  the  surrounding  tis- 
sue." "  The  effects  of  a  gummy  tumor,"  says  Baumler, 
"  may  extend  to  a  great  distance  in  case  it  has  caused 
contraction  of  the  calibre  of  some  vessel,  especially 
of  a  blood-vessel,  which  is  particularly  liable  to  occur 
when  the  tumor  has  its  seat  in  the  adventitia  of  a 
vessel.  Fatty  degeneration  and  wide-spread  processes 
of  softening  may  be  the  consequences  of  a  tumor  in 
itself  insignificant,  as  occasionally  happens  in  the 
brain.  When  situated  in  the  skin,  in  the  subcutaneous 
cellular  tissue,  upon  mucous  membranes  and  superficial 
bones,  the  gumma  often  makes  its  way  to  the  surface, 
since  in  these  situations  it  is  not  uniformly  enclosed  on 
all  sides,  but  is  exposed  to  unequal  pressure.  The 
entire  infiltration  then  ulcerates."  M.  Cornil  still 
later  says  of  the  histology  of  the  ''gummata:"  "  All  the 
pre-existing  cellulo-vascular  tissue  is  thus  infiltrated 
and  crowded  with  cells,  the  enormous  quantity  of  which, 
stra7igles  the  normal  tissue  elements ,  and  impairs  the  cir- 
culationy  ^  It  is  reasonable  to  conclude,  from  the  fore- 
going facts  and  views,  that  contraction  of  vessels,  often 
plays  an  important  part  in  causing  the  lesions  of 
so-called  tertiary  syphilis :  a  purely  mechanical  matter 
quite  independent  of  the  influence  of  any  virus.  In 
passing,  I  desire  also  to  call  your  attention  to  the 
statement  of  Baumler,  "  that  gumma  often  makes  its  way 

*  "Cornil  on  Syphilis,"  Am.  ed.,  Henry  C.  Lea's  Son  &  Co.,  Phila., 
1883;  p.  207.  Ibid.,  at  pp.  208  and  209,  illustrations  are  given  of  the 
planner  in  which  these  cells  obstruct  and  obliterate  capillaries  and  vdng. 


SYPHILIS  AND   THE   GENITO-URINARY  DISEASES.    1 3/ 

to  the  surface."  I  hope  to  be  able  subsequently  to 
show  how  this  occurs — not  making-  its  way,  but  pro- 
gressing, by  natural  forces,  in  line  of  the  natural  physio- 
logical channels. 

Ricord  claims  that  tertiary  lesions  are  not  inoculable, 
and  cannot  be  transmitted  by  hereditary  descent. 
Bumstead  states,  in  his  last  edition,  after  reviewing 
this  matter,  "  Hence  we  consider  the  blood  and  the 
secretions  in  tertiary  syphilis  innocuous."  *  "  Diday 
performed  inoculations  with  the  blood  of  persons  in  the 
tertiary  stage  of  syphilis,  and  invariably  with  a  negative 
result.  Von  Barensprung  states  that  from  observation 
as  well  as  experiment  he  is  persuaded  that  so  soon  as 
the  syphilis  has  passed  into  the  destructive  forms  of  its 
tertiary  stage,  it  ceases  to  generate  an  inoculable  vi- 
rus," and,  says  Baumler,  "  chnical  observation  seems  to 
confirm  this  view,  both  in  respect  to  direct  contagion 
and  with  reference  to  the  inheritance  of  the  disease."  f 

These  authorities,  together  with  Lee,  Hutchinson, 
Lancereaux,  and  many  others  of  our  best  clinical  and 
scientific  observers,  thus  agree,  fully,  on  this  very  im- 
portant point.  What  then,  is  there  to  show  that  the 
so-called  "period  of  gummy  products"  (Lancereaux)  is 
not  simply  a  period  of  sequelae,  when  they  are  found, 
practically,  by  competent  observers,  to  be  free  from  the 
contagious  property,  and  when  by  scientific  investi- 
gators it  is  shown  that  they  are  capable  of  producing, 
without  a  vims,  all  the  lesions,  without  exception,  which 
ever  occur  in  the  so-called  tertiary  or  gummy  stage  of 
syphilis  ? — producing  them,  too,  simply  by  interference 
with  function  of  vessels  and  organs,  not  improbably 
through  pressure,  occasioned  by  th.Q  presence  of  ab- 
normal, or  excessive  accumulations  of  material,  which 
the  most  experienced  and  learned  microscopists,  cannot 
distinguish,  from  the  normal  elements  of  new  forma- 
tions. 

If  then  we  accept  the  lesions  of  the  so-called  tertiary 
stage  (or  the  period  of  gummy  products  of  Lancereaux) 

*  Venereal  Diseases,  Bumstead  and  Taylor,  p.  448. 
j"  Ziem§sen's  Cyclopaedia,  Am.  ed.,  iii.  57, 


138  PRACTICAL   CLINICAL  LESSONS   ON 

as  sequelge,  where  shall  we  look  for  the  causes  of  the 
undue  accumulations  of  normal  germinal  material,  at 
every  point  in  the  human  organism,  which  are  known 
to  occur  as  a  sequence  of  syphilis  ?  Naturally,  it  appears 
to  me,  in  interferences  with  the  lymphatic  channels, 
through  which,  according  to  Rindfleisch,  the  nutritive 
material  exuded  into  the  tissues,  in  excessof  the  neces- 
sities of  growth  and  repair,  is  returned  to  the  general 
circulation."^ 

According  to  the  same  distinguished  authority,f 
"  Luxurious  new  formations,  catarrhs,  and  surface 
secretions  of  all  kinds,  must  be  produced  when  the 
lymph  conveyance  is  hindered,  and,"  he  further  says, 
*'  we  will  find  this  position  in  pathology  very  frequently 
confirmed."  One  thing  is  now  admitted  by  all  recent 
accepted  authorities,  namely,  that  all  the  surface 
secretions  and  new  formations  of  the  tertiary  or 
gummy  period,  all  the  infiltrations  and  tumors,  all  the 
peccant  elements  which  produce  the  varied  lesions  in 
the  skin,  in  the  cellular  tissue,  in  the  bones,  in  the 
viscera ;  by  whatever  name  characterized,  are  but  the 
various  forms  of  infiltration  or  deposit  of  gummy 
material.  If  this  is,  as  it  would  appear  by  the  results 
of  scientific  investigation  to  be,  nothing  more  nor  less 
than  normal  germinal  elements,  thus  retained  at  various 
points,  then  the  only  legitimate  way  of  accounting 
for  this  retention,  would  appear  to  be  through  ob- 
structions, "  hindrances  to  the  lymph  conveyance," 
which,  Rindfleisch  insists,  is  of  itself  sufficient,  inde- 
pendentty  of  an}^  question  of  sj^philis,  to  produce  just 
such  results  as  are  known  to  occur  in  the  so-called 
tertiary  stage  or  period  of  gummy  products. 

And  yet  another  circumstance  would  favor  this 
view  :  clinical  experience  has  shown  conclusively  that 
whatever  the  form  or  locality  or  name  of  a  lesion, 
whether  in  the  skin  as  a  scaling  eruption,  or  as  a  tuber- 
cular eruption,  or  as  a  heaping  up  of  gummy  exudation 
in  scabs,  with  or  without  ulceration,  or  as  an  ulcerative 


*  Rindfleisch,  Pathological  History,  Am.  ed.,  1871,  p.  93. 
f  Ibid.,  p.  93. 


SYPHILIS  AND   THE   GENITO-URINARY  DISEASES.    1 39 

loss  of  tissue,  or  whether  as  a  gummy  tumor  in  the 
cellular  tissue,  in  the  bones,  in  the  viscera,  or  in  the 
brain  and  nervous  system — one  and  the  same  treatment 
is  adopted  and  found  most  efficacious  and  judicious 
for  all,  namely,  the  administration  of  mercury  and  the 
iodide  of  potassium.  I  have  not  heretofore  objected  to 
the  term  gummy  period  (so  called  only  from  the  simi- 
larity of  its  products  to  the  viscid  material  which  it  was 
believed  to  resemble),  nor  to  the  term  tertiary,  which 
is  a  purely  arbitrary  one  ;  but  it  appears  to  me  that  we 
may  now  venture  to  substitute  for  these  the  period  of 
lymphatic  obstruction,  as  more  scientific,  because  ex- 
pressing the  localization  of  lymphatic  elements,  which  is 
proven  to  occur,  and  as  suggesting  the  lymphatic  canal 
system  as  among  the  possible  causes  of  that  localization. 
It  appears  to  me  that,  inasmuch  as  it  has  been  shown 
that  the  lymphatic  spaces  and  vessels  are  primarily  and 
chiefly  affected  and  obstructed,  during  the  active  stage 
of  syphilis,  it  is  not  unreasonable  to  infer  that  damage 
might  have  occurred  to  those  spaces  and  vessels,  during 
the  active  period  of  syphilis,  which,  if  properly  investi- 
gated, would  lead  to  the  true  explanation  of  the  failure 
of  that  system,  to  return  to  the  general  circulation,  the 
germinal  material  exuded  or  developed  in  the  tissues, 
in  excess  of  the  necessities  of  growth  and  repair,  such 
as  is  practically  demonstrated  to  have  occurred  in  the 
so-called  tertiary  or  gummy  period  of  syphiHs.  There 
are  various  known  facts  and  analogies  which  afford 
strong  presumptive  and  circumstantial  evidence  that 
this  view  is  the  correct  one.  Among  these  we  have, 
first,  the  fact,  generally  recognized,  that  the  more  severe 
and  prolonged  the  secondary  or  active  stage  of  syphilis 
the  more  certain  and  severe  are  the  so-called  tertiary 
or  gummous  manifestations.*^  Second,  the  results  of 
treatment  show,  that  the  difficulty  is  not  simply  an 
aggregation  or  infiltration  of  material,  which,  when 
removed,  restores  the  patient  permanently,  but  that  the 
conditions  for  its  reproduction  remain,  and  relapses 
occur. 

*  Hutchinson,  London  Lancet,  January  31,  1874,  p.  159. 


140  PRACTICAL  CLINICAL  LESSONS  ON 

Thus  the  iodide  of  potassium,  is  recognized  as  capable 
of  most  rapidly  removing  the  gummous  material,  and 
thus  of  relieving  symptoms ;  but  mercury  is  found 
requisite  to  produce  permanent  immunity.  The  iodide 
of  potassium,  acts  readily  in  removing  recent  new  for- 
mations and  cell  accumulations,  probably  through  the 
iodine  it  contains.  The  fucus  vesiculosus,  a  remedy  in 
use  for  obesity,  and  popularly  known  as  "  antifat,"  owes 
its  virtues  to  the  same  ingredient.  But  mercury  is 
known  not  only  to  hasten  dissolution  and  elimination  of 
fatty  matters  and  new  formations :  it  is,  besides,  the  only 
agent  with  which  we  can  expect  to  disintegrate  more  or 
less  long-standing  fibrous  obstructions. 

In  the  gummy  accumulations  of  so-called  tertiary 
syphilis,  we  are  obliged  to  infer  that  some  condition 
remains,  after  the  removal  of  this  material,  which 
predisposes  to,  or  causes  subsequent  reaccumulation. 
What  is  more  likely,  than  that  such  condition,  consists 
in  obstruction  of  lymphatic  vessels,  the  ofhce  of  which 
is  to  carry  just  such  material  as  we  find  producing  the 
difficulty?  Vessels,  too,  that  have  been,  more  than  any 
other  structures,  involved  in  recognized  troubles  during 
the  active  stage  of  the  disease.  More  or  less  inflam- 
matory action,  usually  of  a  very  low  grade,  is  recog- 
nised at  different  superficial  points  in  the  lymphatic 
system  during  this  period.  The  well-known  tendency 
of  all  such  action,  is  to  the  deposit  of  fibrous  material — 
the  very  material  through  which  cicatricial  contractions 
of  other  tissues  are  brought  about.  Analogous,  in  a 
degree,  are  the  conditions  which  result  in  stricture  of 
the  urethral  canal,  ten,  twenty,  or  even  forty  years  after 
the  original  inflammation  :  conditions  which  set  in  mo- 
tion a  process  which  culminates,  finally,  in  obstruction 
to  the  passage  of  urine. 

It  has  been  claimed  that  much  of  the  trouble,  in 
so-called  tertiary  syphihs,  may  be  the  result  of  wide- 
spread fatty  degeneration  caused  by  obstruction  of 
ves'sels. 

It  is  well  known  that  fatty  metamorphosis  occurs 
more  easily  in  some  subjects  than  in  others — that 
purulent  degeneration  is  most  readily  set  up  in  the 


SYPHILIS   AND   THE   GENITO-URlNARY   DISEASES,    14! 

debilitated  and  diseased.  It  is  also  claimed  by  Hutch- 
inson and  others  that  the  liability  to,  and  severity  of,  the 
lesions  of  the  so-called  tertiary  period  of  syphilis  "  is 
in  proportion  to  the  duration  of  the  secondary  stage." 

Hence  we  may  conclude,  that  the  varied  degrees  and 
forms  of  so-called  tertiary  manifestations,  depend  upon, 
first,  the  damage  caused  during  the  "  duration  of  the 
secondary  stage,"  and  inferentially  in  consequence  of 
it ;  and,  secondly,  upon  the  condition  of  the  individual 
affected,  and  this  quite  independently  of  any  specific 
virus. 

Notwithstanding  the  variety  in  locality,  physical 
characteristics,  and  date  of  appearance,  the  sequelae  of 
syphilis  practically  call  for  the  same  remedial  measures. 
Whether  it  be  a  superficial  scaling  or  a  tubercular  erup- 
tion, an  ulcerative  lesion  of  the  integument,  an  osseous 
swelling  or  a  necrosis,  a  tumor  in  the  cellular  tissue  or 
in  the  brain,  or  in  any  other  organ  or  locahty  ;  whether 
it  be  a  painless  hypertrophy  of  the  tongue  or  of  the  testi- 
cle, no  matter  how  slight  in  degree  or  how  destructive, 
all  the  lesions  of  this  period  are  most  efficiently  treated 
by  some  form  of  mercurial,  combined  with  the  iodide  of 
potassium.  It  is  only  necessary  to  know  that  the  lesion 
presenting,  is  a  legitimate  sequel  of  syphilis,  to  deter- 
mine the  character  of  the  remedy  to  be  used.  The  form, 
the  size,  and  the  frequency  of  dose  will  be  suggested  by 
the  circumstances  of  each  case ;  but  the  agents  through 
which  Ave  may  expect  the  most  rapid  removal  of  the 
so-called  "gummous  material,"  upon  the  presence  of 
which  we  are  warranted  in  believing  that  all  the  trouble 
depends,  are  mercury  and  the  iodide  of  potassium.  It 
is  the  living  material,  obstructing  nutrition  of  parts, 
which,  in  every  instance,  produces  the  destruction  of 
tissue,  as  well  as  disturbances  of  function,  that  charac- 
terize the  sequelae  of  syphilis.  This  is  the  inevitable 
conclusion  to  which  we  are  led,  by  the  published  results 
of  examinations,  made  by  the  most  accomplished  patholo- 
gists of  modern  times.  Thei-e  is  no  disagreement  in  re- 
gard to  the  presence  of  the  so-called  "gumma"  of  syphilis 
in  all  such  cases.  Destruction  from  the  influence  of  syph- 
ilis may  occur  at  any  point  where  lymphatic  vessels  are 


142  PRACTICAL  CLINICAL  LESSONS  ON 

present — in  other  words,  at  any  point  to  which  nutritive 
material  is  carried  ;  not  only  to  the  skin,  the  cellular, 
muscular,  bony,  and  even  cartilaginous  structures,  but 
to  every  part  of  the  brain  and  nervous  system.  It  will 
also  be  found  that  the  behavior  of  tissues  and  struc- 
tures, infiltrated  with  the  so-called  gummy  material  of 
syphilis,  in  all  forms  in  which  it  presents  a  destructive 
result,  shows  nothing,  either  by  inoculation  or  by  any 
physical  property,  which  proves  it  capable  of  acting 
otherwise  than  by  the  mechanical  influence  of  its  pres- 
ence, by  interfei"ing  with  function  and  cutting  off  nutri- 
tion, through  diminishing  the  calibre  of  blood-vessels, 
or  possibly  effecting  their  entire  obliteration. 

The  measures,  theoreticall}^,  most  efficient  in  setting 
up  a  tissue  metamorphosis  in,  and  removing  this  gummy 
material,  are  those  which,  practically  and  clinically,  are 
found  most  promptly  serviceable  in  curing  the  late 
lesions  of  syphilis.  In  point  of  fact,  it  is  so  well  under- 
stood that  mercury  and  the  iodide  of  potassium,  when 
judiciously  administered,  have  a  specific  influence  in 
curing  the  sequelse  of  syphilis,  of  whatever  form  or 
degree,  that  whenever  a  case  occurs  in  which  the 
diagnosis  is  doubtful  it  is  customary  to  test  the  charac- 
ter of  the  lesion  in  question,  by  use  of  these  remedies : 
failure  to  relieve,  constituting  a  positive  evidence  against 
the  syphilitic  origin  of  the  trouble. 

The  administration  of  mercury  and  the  iodide  of 
potassium,  combined,  is  found  most  serviceable  in  the 
early  syphilitic  sequin,  as  for  instance,  in  the  tubercular 
eruptions  which  may  appear  before  the  contagious 
syphilitic  principle  has  been  eliminated  from  the  affect- 
ed organism,  that  is  to  say,  within  the  first  two  or  three 
years  from  the  date  of  the  acquirement  of  the  disease. 

These  remedies,  combined  as  in  the  following  formula, 
are  usually  well  borne : 

]^     Biniodide  of  mercury gr.   iii. 

Iodide  of  potassium 3  iii-vi. 

Tr.  of  orange  peel 

Syrup  of  orange  peel aa  §  i. 

Aquae ad,  5  viii, 

M. 
Sig. — A  teaspoonful,  thrice  daily,  after  meals. 


SYPHILIS  AND  THE   GENITO-URINARY   DISEASES.    I43 

As  the  ordinary  teaspoon  holds  somewhat  more  than 
a  drachm,  it  will  be  found  that  the  patient  in  the  above 
prescription  will  get  one  sixteenth  gr.  of  the  biniodide, 
and  about  4  to  8  grains  of  the  iodide  of  potassium  at  a 
dose. 

The  same  may  be  judiciously  used  in  every  form, 
stage,  and  date  of  syphilitic  sequelas.  If,  however,  the 
lesion  is  one  where  destructive  action  is  a  prominent  feat- 
ure, or  the  brain  or  nervous  system  is  the  seat  of  the 
affection,  the  iodide  of  potassium  may  be  increased  by 
the  addition  of  a  drop  of  the  saturated  solution, 

Iodide  of  potass 3  viii. 

Distilled  water 3  viii. 

M. 

at  every  dose,  in  from  a  wineglass  to  a  tumbler  of  milk 
or  water  (preferably  the  former),  up  to  60  or  80  drops, 
or  until  troublesome  iodism  results.  The  favorable 
effect  of  this  treatment  may  be  often  seen  within  a 
few  days,  but  occasionally  no  benefit  will  be  observed 
until  the  dose  of  the  iodide  has  reached  a  very  high 
point,  viz.,  a  drachm  at  a  dose,  and  in  cases  of  cere- 
bral gummata  this  dose  may  require  to  be  continued 
over  a  very  long  period — several  months,  or  even 
longer.  In  the  very  largest  majority  of  cases  the 
foregoing  plan  may  be  successfully  pursued,  varying 
the  amount  of  mercurial,  or  of  the  iodide,  within  the 
limits  indicated,  in  proportion  to  the  gravity  and  urgency 
of  the  case.  The  mercurial  reaches  its  limit  of  efficiency 
when  the  constitution  becomes  slightly  affected  by  it, 
as  indicated  by  softening  or  tenderness  of  the  gums 
and  teeth,  and  should,  at  that  limit,  always  be  stayed. 
Should  the  iodide  of  potassium  fail  of  toleration,  the 
iodide  of  sodium  may  be  substituted  and  better  borne 
in  the  same  doses.  If  still  iodism  quickly  result,  as  in- 
dicated by  irritation  of  mucous  membrane  of  the  dis- 
gestive  tract,  the  tincture  of  iodine  may  be  adminis- 
tered in  doses  of  10  to  40  drops  in  a  wineglass  of 
starch  as  prepared  for  laundry  use,  or  what  in  my 
experience   has    often    been    a   most   serviceable    and 


144  PRACTICAL  CLINICAL  LESSONS  ON 

agreeable  substitute  for  the  iodide  of  potassium  and 
sodium,  viz : 

^     Iodine  (crystals) gr.  xviii. 

Iodide  of  potassium 3  i-iii 

Water q.  s. 

Stuart's  syrup  or  plain  molasses to  §  viii. 

M. 

Let  stand  12  hours. 

Sig.  From  a  dessert  to  a  tablespoonful,  three  or  four 
times  a  day,  after  meals. 

Cod-Hver  oil  is  always  indicated  in  cases  when  any 
cachexia  is  present,  from  syphilitic  influence,  or  debility 
from  any  other  cause.  The  diet  should  be  simple  and 
nutritious,  and  adapted  judiciously  to  the  condition  of 
the  patient.  Stimulants  should  be  denied  except  in 
cases  of  especial  urgency  on  account  of  habitual  use  and 
great  debility — red  wines  may  be  permitted,  at  meals,  in 
moderate  quantity. 

The  pursuance  of  the  general  plan  just  presented, 
covers  all  cases,  as  far  as  internal  remedies  are  con- 
cerned. Mercurial  fumigations  may  be,  and  often  are, 
promptly  serviceable,  especially  in  the  ulcerative  le- 
sions, and  may  be  substituted  for  the  internal  administra- 
tion of  mercury.  Twenty  grains  of  resublimed  calomel 
may  be  vaporized  in  a  Lee's  lamp,  placed  under  a  cane- 
bottom  chair,  and  the  patient  covered  in  with  a  rubber 
cloak,  or  even  an  ordinary  blanket,  and  this  repeated 
three  or  four  times  a  week — due  care  being  used  to  pre- 
vent taking  cold  after  the  operation — and  continued  until 
the  disappearance  of  the  lesions,  or  the  occurrence  of 
the  specific  effect  of  the  mercurial. 

In  regard  to  local  applications  for  the  non-ulcerating 
forms  of  trouble,  ointments  containing  a  mercurial  in- 
gredient, such  as  the  ung.  mas.  h3^d.,  the  ung.  hyd. 
nitratis,  or  ung.  hyd.  prascip.  alb.,  or  a  combination  of 
the  oleate  of  mercury  (a  6  per  cent  solution),  with  an 
equal  quantity  of  cosmoline  or  vaseline,  is  often  service- 
able, especially  in  the  scaling  and  non-ulcerating  tuber- 
cular eruptions. 

For  local  apphcation  to  open  ulcerations,  or  losses  of 
tissue,  through  the  influence  of  the  so-called  gummy  in- 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.    14$ 

filtration,  especially  when  advancing,  pointed,  and  pain- 
ful, the  powdered  iodoform  is  often  promptly  benenciaL 
In  all  forms  of  open  lesion  of  syphiUtic  origin  this  drug 
appears  to  be  especially  potent  in  its  sedative,  antiseptic, 
and  healing  properties;  perhaps  it  is  the  most  so  of  any. 
Throughout  the  treatment  of  the  sequelae  of  syphilis 
the  effort  to  appreciate  the  causes  of  any  presenting 
trouble — the  influences  local  and  constitutional  which 
may  tend  to  modify,  or  aggravate,  or  interfere  in  any 
way  with  the  favorable  progress  of  recovery  should 
be  unremitting,  and  not  to  rely  upon  or  seek  after  some 
drug  or  prescription  which  is  vaunted  for  the  cure  of 
syphilis.  Judicious  attention  to  the  general  health,  and 
to  the  idiosyncrasies  of  patients,  often  brings  success  in 
cases  which  would  otherwise  result  disastrously.  Many 
subjects  of  syphilitic  sequels,  suffer  greatly  from  the 
apprehension  of  communicating  the  disease  to  others. 
They  are  entitled  to  the  assurance  that  such  troubles 
are  not  contagious,  and  are  of  purely  personal  interest 
after  a  lapse  of  four  or  five  years  from  the  occurrence 
of  the  initial  lesion  of  syphilis,  and  this  whether  a  sys- 
tematic course  of  treatment  has  been  pursued  in  the  in- 
terval or  the  patient  has  been  quite  neglected  in  this 
respect.  It  is  quite  true  that  many  cases  have  been  re- 
ported claiming  communication  of  syphilis  five,  ten,  and 
even  twenty  years  after  the  acquirement  of  the  disease, 
but  a  single  well-observed,  well-authenticated  case,  re- 
ported by  a  competent  authority,  has  not  yet  come  to 
my  knowledge,  nor  have  I  ever  known  such  an  accident 
to  occur  after  three  years  from  the  date  of  the  initial 
lesion. 

CLINICAL    CASES    ILLUSTRATIVE    OF    THE    VARIOUS 
SEQUELS    OF   SYPHILIS. 

Case  I.  W.  W. ;  28,  physician.  In  December,  1874, 
after  repeated  suspicious  connections  during  many 
months,  one  day  discovered  a  small  sore  on  his  penis. 
This  was  treated  simply  and  only  locally,  and  continu- 
ing in  a  sluggish  way  f()r  a  couple  of  months,  when  it 
was  proved  to  be  a  true  initial  lesion  of  syphilis  by  the 


146  PRACTICAL   CLINICAL   LESSONS   ON 

appearance  of  a  well-marked  roseolous  eruption  and 
mucous  patches  in  the  throat.  A  systematic  mercurial 
treatment  was  then  initiated,  bringing  the  system 
gently  under  its  influence,  and  continuing  at  the  point 
of  easy  toleration,  occasionally  pushing  it  up  to  sensi- 
tiveness of  the  gums  or  teeth.  When  this  occurred  the 
iodide  of  potassium  was  substituted  until  all  evidences 
of  the  mercurialisra  had  disappeared,  and  then  the  mer- 
curial was  resumed,  either  in  the  form  of  pil.  duplex 
(mass,  hydrarg.,  2  grs.;  ferri  exsic,  i  gr.)  or  pil.  pro- 
to-iodid.  hydrarg.  (-J  gr.),  three  times  daily.  Under  this 
treatment,  borne  satisfactorily  for  eighteen  months, 
no  further  manifestations  of  syphiHs  occurred.  The 
glands  in  the  groin  and  cervical  regions,  and  also  in  the 
epitrochlear  spaces,  which  were  characteristically  en- 
larged at  the  date  of  discovery  of  the  roseola,  had  ap- 
parently become  reduced  more  than  one  half  in  size. 
It  was  confidently  asserted  by  the  doctor  that  his 
glands  were  enlarged  for  years  before  the  discovery  of 
the  initial  lesion,  and  were  now  as  small  as  he  remem- 
bered ever  to  have  seen  them.  In  consequence  of  this 
statement,  in  connection  with  the  entire  absence  of  any 
congestion  of  the  faucial  mucous  membrane  or  any  ab- 
normal appearance  at  the  site  of  the  initial  lesion  or  any 
evidence  of  syphihs  at  any  other  point,  all  treatment  was 
suspended.  After  six  months,  during  which  there  was 
no  sign  of  trouble  of  any  sort,  local  or  general,  atten- 
tion was  called  to  a  cluster  of  dark  red  papules  (twenty 
to  thirty),  about  the  size  of  a  small  split  pea,  situated 
on  the  integument  of  the  left  temporal  region.  They 
were  quite  prominent,  insensitive,  and  while  firm  to 
touch  had  a  juicy,  semi-transparent  appearance  at  the 
centre.  On  examination  another  patch  of  similar  erup- 
tions nearly  as  large  as  the  hand  was  discovered  under 
the  left  scapula.  These  clusters  of  apparent  papules 
constituted  a  typical  illustration  of  the  simplest  form  of 
the  tubercular  syphilide,  one  of  the  most  common  and 
earliest  of  the  sequelae  of  syphilis.  Treatment  by  a 
combination  of  mercury  and  the  iodide  of  potassium 
(mist,  biniodid.  hydrarg.,  No.  ,  page  )  was  at  once 
commenced,  and  continued  steadily,  the  eruption  for 


SYPHILIS   AND   THE   GENlTO-URlNARY   DISEASES.    I47 

a  time  increasing  in  prominence.  At  two  points  alone 
slight  ulceration  occurred,  and  a  scab  about  the  size  of 
a  five-cent  piece  was  formed.  After  about  four  weeks 
the  tubercles  began  to  decline,  Avith  slight  desquamation, 
and  finally  to  sink  below  the  surface,  so  that  by  the 
third  month  of  treatment  the  only  remaining  evi- 
dence was  a  cicatricial  depression  on  the  site  of  each 
tubercle ;  the  intervening  spaces  between  these  points 
being  of  a  faint  coppery  hue.  Treatment  discontinued, 
but,  in  a  month,  several  tubercles  had  returned,  and  again 
disappeared  under  same  treatment  as  before — mild  mer- 
curial ointment  (ung.  hyd.  nit.  et  vaseline,  aa  §  ss) — 
applied  locally  for  two  months.  Again,  on  remitting 
treatment,  in  a  week  or  two,  evidences  of  return  of  the 
trouble  on  the  side  of  the  forehead  were  visible  ;  several 
spots  were  simply  reddened,  while  small  scabs  formed 
on  others.  The  treatment  was  resumed,  and  re-enforced 
by  fumigations  with  the  re-sublimed  calomel  tri-weekly, 
and  this  continued  steadily  for  three  months,  when, 
no  evidence  of  the  return  of  the  trouble  presenting,  the 
cicatricial  spots  distinctly  paler  than  the  surrounding 
skin,  and  the  coppery  stain  scarcely  noticeable,  the 
treatment  was  again  discontinued.  August,  1881,  the 
doctor  called  with  the  statement  that  he  was  about  to  be 
married  unless  some  important  objection  should  be 
raised.  The  cicatricial  depressions  were  still  distinct  in 
both  locaUties  and  quite  white,  and  no  evidence  of 
activity  of  the  former  trouble.  Glands  in  the  various 
localities  were  distinct,  but  not  changed  by  time  or  treat- 
ment since  the  cessation  of  active  medication,  eighteen 
months  after  infection. 

Thus  a  period  of  five  years  had  then  elapsed  since 
any  sign  of  activity  of  the  disease  had  been  manifested, 
and  it  was  concluded  that  there  was  no  valid  reason  for 
postponing  marriage, — always  excepting  the  possibility 
of  some  future  trouble  of  local  character,  but  not  suscep- 
tible of  hereditary  transmission.  Now  up  to  February, 
1883,  he  has  had  no  further  trouble;  has  a  wife  and 
child,  now  eight  months  old,  perfectly  well. 

Remarks. — As  recent  painless  enlargement  and  indura- 
tion of  lymphatic  glands  (first,  those  directly  connected 


148  PRACTICAL  CLINICAL  LESSONS  ON 

with  the  initial  lesion  of  syphilis ;  and  second,  groups 
of  glands  at  characteristic  points,  such  as  the  cervical 
and  epitrochlear)  are  the  most  certain  diagnostic  signs 
of  the  presence  of  syphilis,  in  a  given  case,  so  their 
gradual  subsidence  is  the  most  sure  evidence  of  the  effi- 
ciency of  treatment,  and  their  final  and  complete  disap- 
pearance the  most  satisfactory  proof  of  the  complete 
cure  of  the  disease. 

It  is,  however,  necessary  to  mention  that  painless  gland 
enlargements  are  present,  in  some  persons,  independent- 
ly of  syphiHs,  or  of  any  distinct  scrofulous  antecedents 
or  evidences  of  this  or  any  other  dyscrasia.  Hence  it 
becomes  important  to  note  the  condition,  in  this  respect 
of  any  person,  presenting  with  known  or  suspected 
initial  lesion  of  syphilis,  not  only  for  the  diagnostic 
value  attaching  to  recent  painless  gland  enlargements, 
but  as  an  aid  in  determining  the  proper  duration  of  con- 
stitutional treatment.  When  the  glands  are  in  nor- 
mal condition  at  the  time  of  inoculation  of  syphilis — i.e., 
not  susceptible  of  recognition  by  the  touch — a  continua- 
tion of  the  treatment  is  necessary  until  their  restoration 
to  such  condition.  On  the  other  hand,  when  apprecia- 
ble gland  enlargements,  are  present  before  the  system 
is  invaded  by  the  sj^philitic  influence,  there  will  be  no 
such  guide  for  the  cessation  of  treatment,  and  a  much 
longer  period  will  be  required,  before  the  patient  can  be. 
assured  of  the  propriety  of  discontinuing  anti-syphilitic 
remedial  measures. 

The  administration  of  mercury  by  fumigation,  as  in 
the  foregoing  case,  while  not  suitable  for  general  sys- 
tematic treatment,  is  an  excellent  adjunct  in  certain 
cases.  The  necessity  of  a  prolonged  feeble  mercurial 
influence  is  best  met  by  its  judicious  internal  adminis- 
tration, but  in  cases  where  this  is  not  well  borne,  it  may 
be  supplemented  by  two  or  three  fumigations  a  week — 
steadily,  if  practicable,  or  at  intervals,  when  it  appears 
desirable  to  produce  the  constitutional  evidences  of  the 
mercurial  influence.  It  is  especially  adapted  to  cases 
where  eruptive  and  ulcerative  troubles  are  present.  The 
method  of  application  is  exceedingly  simple.  An  ordi- 
nary tin  basin  set  upon  a  couple  of  bricks,  high  enough 


SYPHILIS  AND   THE   GENITO-URINARY  DISEASES.    149 

to  admit  a  small  alcohol  lamp  to  be  placed  under  the 
basin.  From  fifteen  to  thirty  grains  of  pure  calomel  (re- 
sublimed  to  carry  off  the  free  hydrochloric  acid,  which 
is  very  irritating  to  the  respiratory  apparatus)  is  placed 
in  the  basin  over  the  lamp.  This  under  a  cane-bottomed 
or  open-worked  chair.  The  patient  sits  on  this  naked, 
and  is  then  enveloped  closely  in  an  ordinary  blanket — 
the  lamp  is  lighted,  and  in  the  course  of  from  ten  to 
twenty  minutes  the  calomel  is  vaporized,  and  deposited 
to  a  greater  or, less  extent  on  the  surface  of  the  body. 
Still  wrapped  in  the  blanket,  or  slipping  on  a  flannel 
night-dress,  the  patient  gets  at  once  into  bed,  and  re- 
mains through  the  night.  During  the  fumigation  the 
vapor  may  be  inhaled  from  time  to  time  to  advantage, 
especially  if  there  are  open  lesions  of  the  mouth  or 
throat,  or  if  a  prompt  mercurial  effect  is  desired.  If 
an  irritative  cough  results,  inhalation  should  be  very 
limited,  or  suspended  entirely.  Where  it  is  available, 
the  fumigation  lamp  invented  by  Mr.  Henry  Lee  of 
London,  and  in  general  use  under  the  name  of  Lee's 
lamp,  is  preferable.  In  this  a  small  amount  of  water  is 
evaporated  with  the  calomel.  An  ample  water-proof 
garment  in  place  of  the  blanket  is  also  an  improvement, 
but  the  results  are  fully  much  the  same  as  with  the 
simpler  apparatus.  There  is  no  more  danger  of  taking 
cold  after  a  mercurial  bath  or  fumigation  than  after  a 
simple  warm  bath,  but  it  is  desirable  to  secure  a  tem- 
perature in  the  room  of  about  70°  F,,  and  to  have  the 
patient  clad  habitually  in  flannels,  light  or  heavy  accord- 
ing to  the  season,  throughout  the  period  during  which 
the  baths  are  administered.  When  the  mercurial  fumi- 
gation is  relied  upon  alone,  and  the  patient  is  robust,  it 
may  be  used  nightly,  using  ten  to  sixteen  grains,  and 
continued  for  months  without  producing  the  apparent 
constitutional  effects.  If,  however,  signs  of  the  mercu- 
rial influence  appear  in  the  mouth  and  breath,  the  fumi- 
gations should  be  promptly  suspended.  The  incon- 
veniences attendant  on  this  mode  of  treatment  are  such, 
that  except  it  is  manifestly  the  only  way  the  mercurial 
can  be  efficiently  introduced,  the  treatment  by  innunc- 


150  PRACTICAL   CLINICAL    LESSONS   ON  _     ^ 

tion,  or  through  internal  remedies  will  be  found  greatly 
preferable. 

Case  II.  June  loth,  1874,  N.  L.,  46,  naval  officer, pre- 
sented with  a  general  and  quite  profuse,  large,  ham- 
colored,  papular  eruption,  slightly  scaling  at  borders, 
of  some  papules,  chiefly  on  body  and  legs  and  arms, 
none  on  face.  Mucous  patches  in  the  mouth  ;  well-marked 
gland  enlargements  in  the  cervical  region,  viz.  along 
the  posterior  border  of  the  sterno-cleido-mastoid  muscle 
and  of  the  trapezius,  also  in  the  epitrochlear  and  in  the 
inguinal  regions.  On  further  examination,  an  indurated 
lump,  the  size  of  a  pea,  was  found  in  the  tissues  of  the 
prepuce  on  the  left  side.  This  was  said  to  have  come 
with  a  small  sore  some  six  months  previously.  Had  con- 
sulted several  surgeons,  who  thought  his  sore  a  simple 
one.  It  finally  healed,  after  several  weeks'  continuance, 
through  simple  applications  alone,  but  left  a  hard  kernel 
on  its  site.  No  more  attention  was  paid  to  the  matter 
until  the  appearance  of  the  eruption,  some  three  weeks 
previously,  when  he  was  suffering  from  a  supposed 
malarial  attack.  Having  now  some  suspicions  that  his 
trouble  was  syphilitic,  and  not  then  desirous  of  confiding 
in  the  medical  officer  of  his  ship,  he  waited  without 
treatment  until  his  arrival  in  port.  The  case  was  one 
of  undoubted  syphilis  in  full  bloom,  and  was  at  once  put 
upon  a  systematic  mercurial  treatment.  This  was  car- 
ried on  now  under  the  care  of  another  surgeon — a  most 
accomplished  medical  man — for  about  a  year.  During 
this  time  several  consultations  wei"e  held.  The  eruption, 
and  all  other  external  lesions,  passed  off  satisfactorily. 
The  chief  difficulty  experienced  was  a  failure  to  produce 
the  constitutional  effect  of  mercury  by  the  ordinary 
means.  Three  at  first,  then  four,  five,  and  even  six  pil. 
duplex  (each  2  grs.  mass,  hydrarg.  and  i  of  exsic- 
cated sulph,  of  iron),  were  given  daily,  without  appar- 
ent effect  either  on  the  gums  or  on  the  digestive  appara- 
tus. Patient's  general  health  excellent.  Small  doses 
of  calomel  (^  gr.  every  two  hours)  were  given  then  in 
addition  until  gums  responded,  and  at  the  same  time  a 
bilious  diarrhoea  set  in  and  continued  for  several  days. 
When  this  and  the  other  evidences  of  mercurial  action 


SYPHILIS   AND   THE    GEXITO-URIXARY   DISEASES.    151 

had  completely  disappeared,  the  patient  resumed  the 
mercurial  in  the  form  of  pil.  proto-iodid.  h^xlrarg., 
three  J-gr.  pills,  three  times  a  day.  The  treatment 
was  pursued  steadily,  for  about  three  months,  making 
about  twenty  months  since  the  acquirement  of  the 
disease,  and  over  a  year  of  full  and  systematic  treat- 
ment. This  course  was  remarkably  well  borne,  in  every 
respect,  and  the  patient  was  in  excellent  general  health 
and  spirits.  There  was  now  no  external  evidence  of 
syphilis,  and  the  glands  in  the  various  regions  were  no 
longer  characteristically  enlarged.  Leaving  home  for 
a  three  months'  cruise,  the  patient  returned  presenting 
a  thickly  studded  tubercular  patch  about  the  size  of  his 
hand,  under  the  left  scapula  :  tubercles  size  of  a  grape- 
seed,  and  of  a  pale  purphsh-red  color — with  neither  itch- 
ing nor  tenderness  to  touch.  Another  group,  chiefly  of 
large  tubercles, covered  with  brown  serous  scabs, ranging 
in  size  from  a  pea  to  a  five-cent  piece,  arranged  in  a  horse- 
shoe form  four  or  five  inches  in  diameter,  appeared  on  the 
left  thigh  ;  while  several  small  tubercles  were  scattered 
irregularly  over  the  buttocks, — thus  presenting  a  well- 
marked  specimen  of  the  so-called  tubercular  syphilide 
in  its  several  characteristic  forms:  ist.  The  simple  tu- 
bercular under  the  scapula,  in  an  irregular  patch,  with 
each  tubercle  distinct,  and  of  pale  purplish  hue,  with  no 
tendency  to  ulceration  or  exudation  of  serum  ;  this  kind 
disappearing  slowly  by  absorption  of  the  material  com- 
posing; the  tubercle,  and  leaving  a  distinct  depressed 
cicatrix  to  mark  the  site  of  each.  2d.  The  tubercles 
coalescing  and  extending  by  a  superficial  ulceration, 
exuding  serum  and  forming  brownish  scabs  with  a  ten- 
dency to  the  horseshoe  shape.  In  the  arrangement  of 
this  lesion,  the  scabs,  often  quite  thick,  on  removal 
presented  a  superficial  surface  of  large  florid  granula- 
tions scantily  bathed  in  serum,  and  bleeding  at  slight 
touch.  The  so-called  impetigenous  \AxhQTQv\\?^x  syphilide. 
3d.  Tubercles  from  size  of  a  grain  of  pearl-barley  to  a 
pea,  varying  in  color  from  pale  red  to  purple,  irregularly 
scattered  about;  also  some  larger,  quite  pustular  in  ap- 
pearance, some  with  yellow  and  others  with  scabs  of 
quite  a  dark  brown  color. 


152  PRACTICAL  CLINICAL  LESSONS   ON 

All  these  had  come  on  so  insidiously,  so  entirely  with- 
out pain  or  even  itching,  that  they  had  only  been 
discovered  by  the  patient  to  be  more  than  accidental 
pimples  a  week  or  so  previously,  but  had  evidently  been 
present  a  month  or  more.  The  treatment  was  changed 
from  the  pil.  proto-iodid.  hyd.  to  the  mist,  biniodid. 
hy  drarg.,^  a  teaspoonful  thrice  daily.  Scabs  poulticed  off, 
and  an  ointment  composed  of  nitrate  of  mercury  ung. 
and  vasehne,  equal  parts,  applied  morning  and  night. 
Improvement  followed,  especially  in  the  open  lesions ; 
but  after  a  couple  of  months,  when  the  first  crop  had 
almost  disappeared,  others  appeared  on  the  right  calf. 
Treatment  changed  to  nightly  mercurial  fumigations 
(20  grs.  calomel),  and  increase  in  the  iodide  of  potas- 
sium—increasing from  eight  grains  three  times  a  da}', 
a  drop  for  each  dose,  up  to  sixty,  and  taken  in  a  tum- 
bler of  milk.  After  several  months,  taking  from  fifteen 
to  twenty  fumigations  a  month,  and  keeping  the  iodide 
at  about  sixty  grains  thrice  daily,  the  eruption  entirely 
disappeared,  leaving  slight,  pale,  depressed,  and  corru- 
gated cicatrices  on  the  body,  and  deep  coppery  stains 
on  the  extremities.  The  treatment  Avas  then  omitted, 
the  patient  still  being  in  good  general  health.  Capsules 
of  cod-liver  oil  and  iron  (Mathey  Caylus),  adminis- 
tered. After  a  month  or  so,  other  crops,  chiefly 
pustular,  came  to  the  surface,  apparently  on  the  site  of 
the  former  eruptions,  and  came  and  went  for  the  next  six 
months,  getting  better  in  one  place  and  then  cropping 
out  in  groups  of  half  a  dozen  or  so  in  another,  and  this 
under  a  systematic  treatment  as  before  mentioned,  car- 
ried out  with  as  much  regularity  and  persistence  as  was 
possible  under  the  circumstances.  Relaxing  it,  for  even 
a  few  days,  was  followed  by  more  or  less  return  of  the 
trouble,  and  it  was  fully  two  years  after  the  appearance 
of  the  first  tubercular  eruption  before  the  trouble  entirely 
ceased  to  recur.  During  this  time  no  points  were  at- 
tacked except  those  first  mentioned — under  the  scapula, 
and  on  the  thigh  and  buttocks,  and  soon  after  on  the 
right  calf ;  after  this  the  recurrences  were  in   the  same 

*  See  formula,  p.  92. 


SYPHILIS  AND   THE   GENITO-URINARY  DISEASES.    153 

points  or  in  their  immediate  vicinity.  During  the  entire 
period  covered  by  the  treatment  the  patient  was  most 
of  his  time  at  sea,  under  favorable  hygienic  conditions, 
and  living  a  temperate  and  regular  life.  Within  the 
last  year  (1882)  the  above-mentioned  person  was  seen 
in  consultation  for  what  was  supposed  to  be  a  malarial 
neuralgia.  There  was  no  history  of  any  recurrence  of 
trouble  which  could  be  reasonably  attributed  to  the 
syphilitic  influence  for  the  previous  five  years.  The 
neuralgia,  which  was  chiefly  in  the  muscles  of  the  spine, 
after  resisting  treatment  by  the  iodide  for  several  weeks, 
finally  passed  away  under  the  influence  of  a  month's  so- 
journ in  the  tropics. 

Remarks. — The  chief  interest  involved  in  the  appear- 
ance of  an  eruption,  after  the  eighth  or  tenth  month  of 
syphilis, is  as  to  whether  it  is  to  be  accounted  as  a  se- 
quel of  the  active  disease,  or  is  an  evidence  of  the  active 
presence  of  syphilitic  cell  material  in  the  organism. 
After  the  first  general  papular  eruption,  which,  as  a  rule, 
appears  between  the  third  and  the  seventh  month,  and 
is  more  or  less  symmetrical  in  its  distribution,  groups  of 
papules  may  develop  on  the  shoulder  or  arm  or  back 
or  forehead,  which,  although  usually  darker  and  more 
likely  to  assume  an  annular  or  crescentic  form,  may  pre- 
sent all  the  physical  characteristics  of  the  papules  of  the 
earlier  general  eruption.  These  are  known  as  the  recur- 
ring papular  syphilides,  and  are  supposed  to  be  the  result 
of  a  release  of  accidentally  imprisoned  infective  cell  ma- 
terial from  lymphatic  glands,  in  the  immediate  vicinity 
of  the  eruption,  and  to  indicate  a  continued  activity 
of  the  contagious  element.* 

It  is  quite  impossible,  in  the  present  state  of  our  knowl- 
edge of  this  matter,  to  make  a  positive  diagnosis  in  cases 
of  doubt,  until  sufficient  time  has  passed  to  observe  the 

*  "The  secretions  of  syphilitic  lesions  are  found  to  consist  of  a  serous 
fluid  containing  numerous  shining  granules  or  molecules,  which  are 
masses  of  protoplasm  or  germinal  matter  holding  the  contagious  proper- 
ties of  syphilis.  These  microscopic  bodies  are  probably  taken  into  the 
circulation  by  the  lyi7iphatics  and  conveyed  over  the  body."  (Bumstead 
and  Taylor  on  the  Venereal  Diseases,  fourth  edition.  Henry  C.  Lea, 
Phila.,  1879.     P-  443-) 


154  PRACTICAL   CLINICAL   LESSONS   ON 

manner  in  which  the  tissues  occupied  by  the  eruption, 
are  affected  by  the  presence  and  the  final  absorption  of 
the  material  causing  it.  Thus  the  papule,  having  its 
origin  in  an  accumulation  (proliferation  in  loco?)  of 
germinal  cells  (commencing,  according  to  Kohn  and 
others,  always  in  a  papilla  cutis),  has  several  character- 
istic points.  I  St.  In  certains  cases  the  cells  thus  crowded 
together  ''are  not  destined  to  become  permanently  or- 
ganized, as  they  degenerate  and  disappear,  or  assume  a 
dull  granular  appearance,  undergo  fatty  degeneration 
and  are  absorbed.  Or  they  may  become  heaped  to- 
gether in  the  form  of  detritus  and  form  pus."  * 

Thus  they  either  ''  undergo  fatty  degeneration  and 
become  absorbed,"  leaving  no  loss  of  tissue  to  mark  their 
site,  or  they  become  pustules.  The  tubercle,  on  the  other 
hand,  is  made  up  of  the  so-called  ''gummy'  or  germinal 
material,  identical  with  that  found  in  the  lymph  channels ; 
arrested  by  localized  obstruction  of  such  channels;  this 
localized  accumulation  causing  absorption  of  the  tissue  in 
which  it  is  located, finally  itself  undergoing  fatty  degener- 
ation and  absorption,  a  depression  or  cicatrix  is  left  which 
is  a  sure  diagnostic  mark  of  the  uncomplicated  syphilitic 
tubercle. f  These  so-called  "  gummy  exudations,"  char- 
acterizing as  they  do  all  the  sequelae  of  syphilis  (the 
secretions  of  which  are  non-contagious),  form  the  dis- 
tinguishing feature  between  syphilis,  as  a  contagious 
disease,  and  its  sequelae.  Their  occurrence,  in  what- 
ever locality  or  form,  calls  for  change  or  modification 
in  the  treatment.  Iodine  and  the  iodide  of  potassium 
having  been  found  to  possess  a  peculiar  power  in  caus- 
ing the  fatt}^  degeneration  and  elimination  of  the  so-called 
gummy  material  is  then  found  promptly  efficacious  in 
aiding  in  the  cure.:}: 

*  Caracteres  cliniques  et  histologiques  des  Syphilis,  par  Moritz  Kohn, 
Wiener  Woc^enschrift.  Caracteres,  1870.  No,  55,  Archives  Ghi^rales  de 
M^decitie,  March,  1872. 

f  See  Van  Buren  and  Keyes.  Genito-Urinary  Diseases,  with  Syphilis, 
page  583.     Appleton  &  Co.,  New  York,  1874, 

f  As  these  processes  are  quite  distinct  in  their  origin  they  may  be  pres- 
ent at  one  and  the  same  time,  and  thus  it  may  occur  that  although  the 
tubercular  eruption — a  sequel  of  syphilis — is  present,  the  contagious  ma- 
terial represented  by  the    papule  may  still   exist  in  the  organism  ;  the 


SYPHILIS  AND   THE   GENITO-URINARY   DISEASES.    1 55 

The  punctate  form  of  the  tubercular  syphilide,  as  first 
described,  is  usually  the  earUest  of  the  syphilitic  se- 
quelge,  and  rarely  appears  after  the  third  year.  The  su- 
perficial ulceration,  with  a  tendency  to  the  crescentic,  or 
horseshoe  arrangement,  is  next  in  order,  and,  is  occasion- 
ally associated  with  it,  as  in  the  foregoing-  case,  but  may 
occur  as  late  as  the  tenth  and  even  the  twentieth  year 
after  infection,  and  is  likely  to  be  especially  severe  and 
extensive  in  cases  of  chronic  alcoholism. 

Tubercles  occasionally  appear  singly,  or  in  small 
groups,  on  the  face,  especially  on  the  alae  nasi,  and,  ulcer- 
ating superficially,  become  scabbed  over  and  pursue  a 
very  sluggish  course,  often  for  many  months,  and  are 
not  unfrequently  mistaken  for  simple  lupus.  Under 
favorable  hygienic  conditions,  all  these  forms  yield 
promptly  to  treatment :  locally,  by  iodoform,  or  the  ung. 
hydrarg.  nitratis  and  vaseline ;  and  internally  by  com- 
bination of  mercury  and  the  iodide  of  potassium,  as  in 
the  misturge  biniodid.,  and  additional  iodide  of  potas- 
sium in  doses  increasing  by  one  drop  at  each  dose  up 
to  60,  thrice  daily,  if  well  borne,  always  taken  well  di- 
luted— in  half  a  tumbler,  and  finally  a  tumbler  of  fluid, 
preferably  of  milk.  In  this  way  the  stomach  is  rarely 
rebeUious  to  the  maximum  dose. 

It  is  a  fact  well  understood  by  all  who  have  experi- 
ence in  the  tubercular  forms  of  sj^philis,  that  local  meas- 
ures, while  apparently  hastening  the  cure,  are  almost 
wholly  useless,  except  in  combination  with  mercury 
and  the  iodide  of  potassium.  It  is  also  equally  appre- 
ciated that  while  prompt  benefit,  is  almost  certain  to 
follow  the  use  of  the  iodide  of  potassium,  recurrences 
of  the  trouble  are  much  more  frequent,  than  when  this 

limit  of  contagion  in  acute  syphilis  having  been  ascertained  in  the  very- 
greatest  majority  of  cases  not  to  exceed  three  years.  Bearing  this  in 
mind,  it  may  then  be  said  that  although  the  presenting  lesion  being  tuber- 
cular and  by  its  origin  illustrating  the  non-contagious  stage  of  syphilis, 
yet  it  cannot  be  claimed  as  free  from  virulence  {i.e.,  power  of  contagion) 
until  two  or  more  years  have  passed  and  all  gland  enlargements  depen- 
dent upon  syphilis  have  disappeared  ;  but  that  after  such  proof  of  the  ter- 
mination of  the  acute  stage  of  the  disease,  the  presence  of  such  tubercular 
eruption  would  not  indicate  a  power  to  transmit  syphilis  by  direct  con- 
tact or  through  heredity. 


156  PRACTICAL  CLIXICAL  LESSONS   OX 

remedy  is  used  in  combination  with  a  mild  mercurial 
treatment,  either  internally  oi*  by  innunction  or  fumiga- 
tion. Such  behavior,  which  is  recocrnized  as  a  clinical 
fact,  is  most  significant  of  the  conditions  which  demand 
treatment.  The  accumulations  of  the  arrested  germinal 
material,  or  so-called  gumma,  as  the  immediate  recog- 
nized cause  of  the  local  lesions,  are  readily  acted  uj)on 
by  the  iodide  of  potassium,  (the  weaker  agent  in  pro- 
ducing tissue  metamorphosisX  while  the  permanence  of 
results  is  better  secured  by  the  mercurial,  which  has  the 
greater  power  to  cause  a  modification,  if  not  a  complete 
metamorphosis  of  the  material  causing  the  obstruction. 
In  the  absence  of  absolute  proof,  as  to  the  degree  and 
quality  of  the  obstruction  in  the  lymph  channels,  it  may 
be  possible,  that  this  is  due,  in  some  cases,  to  actual  clo- 
sure by  cicatricial  deposit,  such  as  is  seen  constricting 
the  parenchymatous  structure  of  the  liver,  the  tes- 
ticle, etc.  If  this  is  the  fact,  removal  of  such  obstruc- 
tive material  by  anv  sort  of  treatment  is  scarcely  prob- 
able. This  would  account  for  the  repeated  recurrences 
of  trouble,  temporarily  relieved  b}'  treatment,  and  con- 
stituting a  form  of  what  is  termed  a  syphihtic  dyscrasia. 
It  may  also  be  possible,  that,  where  such  cicatricial  ob- 
literation of  lymph  channels  is  not  extensive,  the  circu- 
lation is  temporarilv  relieved  by  elimination  of  the 
excess  through  treatment,  or  through  fatt}'  metamorph- 
osis, sua  spo7ite,  until  the  dilatation  of  adjoining  or  sub- 
sidiary efferent  channels  shall  afford  permanent  relief. 
It  is  a  clinical  fact  that,  as  in  the  foregoing  case,  relapses 
continue  to  occur  for  vears  even,  and  the  case  is  at 
last  permanently  cured  by  efficient  treatment:  while  in 
others,  the  troubles,  with  or  without  treatment,  remain 
until  the  termination  of  the  hfe  of  the  patient,  notwith- 
standing the  most  judicious  care.^ 

*  However  mnch  the  explanation  of  gmnmons  collections  may  need 
absolute  microscopical  demonstration,  it  is  conceded  by  all  modem  patho- 
looi.5ts:  I  St.  That  the  so-called  gommoos  material  constitutes  in  some  way 
the  sum  and  substance  of  all  the  tertiary  and  qoartemay  lesions:  in  other 

words,  the  sequel/z  cf  syphilis.  2d.  That  this  material  does  not  differ  mi- 
croscopicaHv  in  any  appreciable  way  from  the  normal  germinal  elements, 
such  as  are  found  in  all  the  lymphatic  gland,  channels,  and  spaces  in  the 
human  organism.    If,  then,  this  material  present  to  a  cer^un  d^[cee  in  all 


SYPHILIS  And  the  genito-urinary  diseases.  157 

Case  111.  W.  McN. ;  merchant ;  42.  Temperate,  or- 
dinarily healthy  ;  had  a  well-marked  open  initial  lesion 
of  syphilis  at  25  years  of  age.  This  was  followed  by  a 
general  papular  eruption,  at  about  the  fifth  month.  Treat- 
ment desultory,  until  the  appearance  of  the  eruption, 
when  he  came  under  my  observation,  and  was  put  upon 
pil.  duplex  (mass,  hydrarg.  et  ferri).  This  treatment  was 
well  borne,  and  continued  for  a  year  and  a  hall  very 
steadily;  occasional  intermissions  of  a  few  days  only, 
when  slight  evidences  of  mercurialism  occurred.  With 
the  exception  of  several  mucous  patches  in  the  mouth, 
and  slight  ulcerationof  the  tonsils,during  the  sixth  month, 
there  were  no  open  lesions  of  any  sort.  General  and  local 
gland  enlargements  had  declined  satisfactorily.  The 
patient  at  this  point  was  put  upon  the  mist,  biniodid.  hyd. 
(potas.  iodid.  8  grs.,  hydrarg.  biniodid.  -^V^'  '^  teaspoon- 
full  thrice  daily,  and  it  was  faithfully  continued  for  the 
following  six  months.  During  this  time  the  patient  was 
apparently  in  perfect  health.  At  its  close,  the  only  evi- 
dence of  syphilitic  trouble,  was  the  abnormal,  but  not 
greatly  enlarged,  lymphatic  glands,  at  all  characteristic 
points.  As  these  glands  had  not  diminished,  appreciably, 
during  the  last  six  months  of  treatment,  it  was  concluded, 
in  the  absence  of  knowledge  of  their  condition  before 
the  accession  of  syphilis,  that  they  had  no  longer  any 
pathological  signihcance,  and  all  treatment  was  sus- 
pended. During  the  following  two  years,  no  evidence 
of  syphilis  having  been  manifest,  permission  to  marry 
was  accorded.     Child   born  a  year  after ;  mother  and 

the  tissues — for  all  tissues  are  supplied  with  lymphatic  spaces  or  channels — 
becomes  localized  in  excess  at  certain  given  points,  this  can  logically  only 
occur  by  the  obstruction  of  such  channels  or  spaces.  Whether  we  can 
yet  demonstrate  this  microscoi/ically  or  not.  It  is  within  the  last  ten 
years  that  even  the  existence  of  lymphatic  vessels  in  the  most  im[)ortant 
pans  of  the  body — as,  in  the  eye,  in  the  bones,  etc. — has  been  denied  liy 
leading  and  accepted  authorities.  But  since  then  it  has  been  proven  by 
Thin.  Ludwig,  Schvveigger-Seidel,  anil  others,  that  there  is  not  alone  a  gen- 
erous supply  of  lymphatic  vessels  to  the  eye  and  the  bones,  etc.,  but  even 
cartilages  are  abutulantly  furnished  with  them.  Accepting  thus  a  legiti- 
mate deduction  from  known  facts,  whch  furnish  logical  reasons  for  the 
plan  and  measure  of  treatment,  we  may  wait  hopefully  for  the  microscop- 
ical ailvances  which  shall  scieruifically  establish  our  kiunvledge  of  the 
exact  mechanism  of  the  late  lesions  of  syphilis. 


158  PRACTICAL   CLINICAL  LESSONS   ON 

child  healthy — and  so  continued.  Two  years  subsequent 
to  the  birth  of  the  child,  and  thus  six  years  from  the  ac- 
quirement of  syphilis,  patient  presented  with  a  swelling 
over  the  lower  portion  of  the  sternum,  about  the  size 
of  half  a  lemon  ;  quite  firm  ;  slightly  tender  on  pres- 
sure. First  noticed,  about  half  its  present  size,  about  a 
month  previous.  Diagnosis :  gummy  tumor — a  sequel 
of  former  syphilis.  Treatment :  iodide  of  potassium  8 
grs.,  biniodid.  of  mercury  one  sixteenth,  three  times  a 
day.  As  the  patient  was  otherwise  in  good  health,  noth- 
ing further  was  prescribed.  Without  any  local  applica- 
tion, under  the  above-mentioned  treatment,  the  tumor 
declined  rapidl}^  and  at  the  end  of  three  months 
every  evidence  of  it  had  completely  disappeared,  and  all 
treatment  was  discontinued.  A  little  more  than  ten 
3"ears  have  passed,  and  no  further  trouble  of  syphilitic 
nature  has  occurred,  either  to  the  patient,  his  wife,  or 
his  children,  of  which  latter  he  has  several. 

Remarks  on  Case  III. — Claims  for  the  non-contagious 
character  of  syphilitic  sequelae,  find  corroboration  in 
this  case.  Prompt  effects  of  the  specific  treatment  re- 
move any  possible  doubt  as  to  syphilitic  origin  of  the 
trouble.  The  cessation  of  treatment  on  the  entire 
disappearance  of  the  tumor,  is  in  accordance  with  the 
usual  practice  in  such  cases,  but  it  must  not  be  for- 
gotten that  such  tumors  are  likely  to  return,  or  that 
similar  accumulations  may  occur  at  other  points.  And 
while,  as  in  this  case,  a  prolonged  immunit}'  may  be  ac- 
quired, even  escape  from  any  further  syphilitic  sequelae, 
yet  such  an  accident,  indicating  failure  of  treatment  dur- 
ing the  active  stages  of  syphilis  to  completely  efface  the 
damage  then  done,  must  make  the  patient  and  his  phy- 
sician anxious  and  watchful  for  possible  similar  develop- 
ments in  other  localities.  Especially  should  this  be 
borne  in  mind  when  obscure  troubles  of  nutrition  or 
of  the  motor  or  sensory  apparatus  are  recognized. 

GUMMA   OF  THE   TESTICLE. 

Case  IV.  J.  V.,  65 ;  lawyer,  in  good  general  health. 
Presented  with   an   enlargement   of  the   left   testicle. 


SYPHILIS  AND  THE  GENITO-URINARY  DISEASES.    159 

It  had  a  few  weeks  previously  attracted  his  attention 
by  its  weight,  and  not  from  any  pain  in  it.  The  size  of 
the  organ,  which  was  ovoid  in  shape,  was  four  inches 
in  its  vertical  and  three  in  its  horizontal  diameter, 
quite  firm  and  insensitive  to  the  touch.  A  small 
amount  of  fiuid  was  recognized  in  the  tunica  vaginalis. 
There  was  no  history  of  any  urethral  disease  or  any 
mechanical  injury  either  to  the  testicle  or  the  sur- 
rounding parts ;  but  there  was  a  tolerably  clear  history 
of  syphilis  at  the  age  of  24,  viz.:  a  sore  coming  on  the 
penis  fully  three  weeks  after  a  suspicious  connection, 
which  remained  for  some  time,  finally  healing  under  the 
internal  administration  of  mercury.  He  married  a  few 
years  after ;  had  several  children  ;  also  grandchildren  ; 
not  one  of  whom  had  ever  any  recognized  signs  of 
syphilis.  No  recognized  sign  of  syphilis  had  appeared 
in  the  patient  from  the  date  of  the  healing  of  his  sore, 
to  the  occurrence  of  the  swelling  of  his  testicle,  forty 
years  after.  The  tumor,  both  as  to  its  accession  and 
its  physical  characteristics,  was  like  a  sequel  of  syphilis. 
Freedom  from  pain,  and  from  irregularities  in  shape ; 
freely  movable  under  the  scrotum :  unconnected 
with  any  tubercular  or  cancerous  antecedents.  About 
four  drams  of  serum  were  drawn  from  the  tunica  vagi- 
nalis and  the  smooth  surface  of  the  tumor,  and  com- 
plete freedom  from  fluctuation  was  made  more  manifest. 
Treatment  by  the  mist,  biniodid.  internally,  was  com- 
menced, together  with  ung.  hydrarg.  mit.  externally. 
Subsidence  of  the  tumor  commenced  within  a  fort- 
night, and  at  the  end  of  six  months  the  testicle  had  re- 
sumed, nearly  or  quite,  its  original  size. 

Remarks. — The  absence  of  all  recognized  manifesta- 
tions of  syphilis,  as  in  the  foregoing  case,  is  not  without 
precedent.  Early  constitutional  syphilis  varies  in  its 
intensity  as  much  as  any  other  known  disease.  The 
roseola,  even  if  present,  may  readily  escape  observation. 
The  papular  eruption  may  be  confined  to  half-a-dozen 
points,  or  even  a  single  spot  on  the  body,  or  a  single  mu- 
cous patch  or  tubercle,  which  shall  pass  away  without 
treatment  or  recognition,  and  yet  syphilitic  sequelae  may 


l6o  PRACTICAL  CLINICAL  LESSONS   ON 

occur,  the  effects  of  which  may  prove  as  grave  as  when 
every  phase  of  the  active  period  presents  the  typical 
manifestations.  Once  recognized  as  syphihtic,  no  matter 
how  slight  the  lesions  of  the  initiatory  period  or  that  of 
general  infection,  the  treatment  should  be  as  system- 
atic, as  thoroughly  considered  and  carried  out,  as 
when  well-marked  in  all  respects.  It  is  only  in  this 
way  that  we  gain  the  great  security  against  the  occur- 
rence of  sequelas,  and  if  occurring,  secure  the  lightest 
forms  of  trouble.  Unfortunately,  relief  from  the  im- 
mediate and  appreciable  accumulations  constituting 
sequelse  (the  so-called  gummy  tumors  of  syphilis)  does 
not  always  mean  cure :  recurrences,  especially  of  the 
accumulations  in  the  testes,  are  not  uncommon,  as  in 
the  following  : 

Case  V.  P.  P.  S.  This  patient  gave  a  clear  his- 
tory of  the  characteristic  eruptions  of  active  syphilis 
occurring  twenty  years  ago.  Good  health  up  to  five 
years,  when  his  right  testicle  became  enlarged  to  the 
size  of  his  fist.  He  stated  that  under  occasional  treat- 
ment of  iodide  of  potassium  the  testicle  grew  very 
much  smaller;  in  fact,  he  thought  his  difficulty  almost 
cured,  when  the  swelling  returned.  On  examination,  a 
large  quantity  of  fluid  was  found  in  the  tunica  vagina- 
lis. Four  ounces  being  drawn  off,  it  became  evident 
that  the  tumor  remaining,  while  not  larger  than  a  nor- 
mal testicle,  was  irregular  in  shape — nodulated — espec- 
ially at  the  lower  portion,  where  it  was  of  cartilaginous 
hardness.  The  upper  portion  alone  was  sensitive  to 
pressure.  It  thus  became  evident  that  a  fibrous  de- 
generation of  the  entire  inferior  portion  of  the  testicle 
had  taken  place,  and  that  its  secretory  structure  was 
almost  entirely  destroyed ;  the  sensitiveness  to  pres- 
sure indicating  the  portion  which  had  thus  far  escaped. 

Remarks  on  Case  V. — In  the  post-mortem  exami- 
nation of  similar  cases,  it  is  found  that  two  forms  of 
trouble  frequently  (and  always  in  long-standing  cases) 
unite  in  the  so-called  chronic  orchitis  of  late  syphilis, 
the  one  usually  earliest  to  manifest  itself  being  gen- 
eral infiltration  or  a  localized  tumor  at  one  or  more 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.    l6l 

points  in  the  substance  of  the  or^an.  This  accumu- 
lation is  found  to  be  made  up  of  materials  charac- 
teristic of  the  ^' gummy  tumor'  occurring  in  other 
localities.  Subsequently  to  the  occurrence  of  these 
tumors  a  marked  growth  of  fibrous  tissue  is  found  to 
take  place,  apparently  commencing  in  the  lobular  spaces^ 
and  gradually  encroaching  upon  the  seminal  lobules 
until  they  are  destroyed.  The  elements  of  new  forma- 
tion, traversing  in  this  same  way  the  substance  of  the 
entire  organ  with  a  cicatricial  net-Avork,  the  contrac- 
tion which  naturally  follows  often  results  in  the  total 
destruction  and  almost  complete  disappearance  of  the 
organ.  This  explains  what  we  find  in  the  present  in- 
stance. The  history  points  to  a  general  so-called 
gummy  infiltration,  involving,  probably,  the  epididymis 
and  the  body  of  the  testicle,  and  a  later  development 
of  fibrous  tissue,  which  has,  by  its  subsequent  contrac- 
tion, reduced  the  organ  to  its  present  indurated  and 
atrophied  condition.  It  is  interesting  here  to  recall 
the  fact,  made  prominent  by  all  authorities  on  syphilis, 
that  cicatricial  deposit  and  its  subsequent  contraction 
and  strangulation  of  the  parenchyma  of  the  testicle, 
resulting  in  true  atrophy,  is  characteristic  of  the  influ- 
ence of  late  syphilis,  and  occurs  not  alone  in  the  testi- 
cle, but  notably  also  in  the  liver  and  the  kidneys.  The 
tendency  to  formation  of  fibrous  tissue  has  also  been 
recognized  (from  apparently  the  same  causes)  at  other 
points,  as  in  the  larynx,  intestine,  etc.  Ranvier  and 
Cornil  significantly  remark"^  that  all  profound  syphilitic 
lesions  of  the  mucous  membrane  occasion  a  prolifera- 
tion and  a  production  of  connective  tissue  usually  much 
greater  than  in  diseases  due  to  other  causes.  It  is  a 
.veil  ascertained  clinical  fact  that  gummy  infiltration 
precedes  the  stage  of  cicatricial  deposit,  and  that  while 
both  the  gummy  tumor  and  cicatricial  atrophy,  are 
often  met  with  m  the  same  testicle,  general  enlarge- 
ment first  occurs;  then  comes  the  recognition  of  local- 
ized deposits  of  gummy  material,  and  later,  often  sev- 
eral years  after,  compression,  due   to    contraction  of 

*  "Fatholog.   Histol.,"  page  399,  1880. 


l62  PRACTICAL  CLINICAL  LESSONS  ON 

cicatricial  deposit,  finally  takes  place,  and  atrophy  of 
the  testicle  results.  The  clinical  evidences  are  strongly 
in  favor  of  considering  the  gummy  exudation  as  the 
basis  of  the  cicatricial  deposit,  and  the  different  subse- 
quent conditions,  as  but  stages  of  the  same  pathological 
process,  terminating  finally  in  atrophy,  through  cica- 
tricial contraction.  In  favor  also  of  this  view,  and  as 
affording  a  possible  explanation  of  the  cause  and  mode 
of  formation  of  the  cicatricial  deposits  in  other  organs, 
due  to  late  syphilis,  we  may  recall  the  statement  of 
Rindfleisch  in  regard  to  the  most  favorable  conditions 
for  the  development  of  new  cell  formations,  namely, 
"  Contact  with  tissue  and  relative  rest  of  the  emigrant 
cells  induces  them  first  to  essay  their  amoeboid  mobility, 
and  then  to  division."^  But  absolute  x^^i, stasis oi s\xq\\ 
cells,  or  of  any  cells,  is  necessary  for  their  developmeiit 
into  tissue.  All  fibrous  or  connective  tissue  is  said  to 
be  made  up  of  the  spindle-shaped  or  connective-tissue 
cells  and  fi-brillse  which  are  simply  a  higher  stage  of 
development  of  the  lymphoid  cells  and  corpuscles, 
evolved  from  and  circulating  in  and  through  the  lym- 
phatic organs,  spaces,  and  vessels.  This  is  exactly  the 
essential  material  of  which  cicatricial  tissue,  wherever 
found,  is  made  up,  and  this  is  exactly  the  sort  of  tissue 
which  has  caused  the  mischief  in  this  testicle,  and 
which  by  authorities  is  accepted  simply  as  one  of  the 
many  mysterious  phases  of  the  so-called  tertiary  period 
of  the  disease.  Only  a  single  condition  is  lacking,  how- 
ever, in  order  to  place  this  cicatricial  deposit,  due  to 
syphilis,  in  the  line  of  ordinary  pathological  conditions, 
and  that  is,  one  which  will  account  satisfactorily  for  the 
presence  and  quantity  of  embryonal  or  formative  cells 
in  the  localities  where  the  cicatricial  tissue  is  subse- 
quently developed,  and  the  causes  of  their  enforced 
accumulation  and  stasis  in  those  localities,  during  a 
period  sufficient  for  the  formation  of  such  tissue. 

Ludwig  and  Thomsa  \  claim  to  have  demonstrated  a 


*  Rindfleisch,  "Path.  Hist.,"  p.  94,  sec    77. 

f  Strieker,  "  Human  and  Comparative  Histology,"  Sydenham  ed.i  vol, 
i.,p.  311,  et  seq. 


SYPHILIS   AND   THE   GENITO-URINARY  DISEASES.    163 

very  generous  distribution  of  lymphatic  channels  in  the 
testicle,  the  liver,  and  the  kidneys,  organs  in  which  the 
cicatricial  contraction  due  to  the  influence  of  late 
syphilis  is  chiefly  found.  Especially  are  the  lymphatics 
claimed  to  be  numerous  and  ample  in  the  testicle, 
where  injections  performed  upon  dogs  have  shown  that 
lobular  spaces  are  simply  lymph  sacs  or  lacunae.  In 
point  of  fact,  the  seminal  lobules  are  literally  inclosed 
in  lymph  chambers,  and  the  reticulation  of  lymph 
channels  not  only  surrounds,  but  permeates,  every  por- 
tion of  the  testicle  and  its  appendages.  The  same  rich 
distribution  is  shown  also  in  the  liver  and  kidneys. 
Having,  then,  the  material  necessary  for  the  formation 
of  cicatricial  tissue,  and  in  localities  where  it  is  known 
to  develop,  the  essential  condition  to  produce  it,  is  an 
enforced  stasis  of  cell  elements,  through  interference 
with  the  lymph  circulation  of  these  organs ;  in  short, 
obstruction  of  the  lymph  channels  at  various  points. 

GUMMY  TUMORS   OF   THE   INTEGUMENT  AND   CELLULAR 

TISSUE. 

Case  VI.  W.  W.;  49.  Presented  three  large,  sharp- 
ly cut,  apparent  ulcerations  on  the  inner  aspect  of 
the  right  leg  just  below  the  knee ;  two  about  two  inches 
each  in  diameter,  quite  circular,  and  a  third  about  two 
inches  in  length,  formed  by  the  union  of  two  about  an 
inch  in  diameter.  All  had  penetrated  the  integument 
completely;  the  surrounding  integument  was  only  slight- 
ly inflamed.  Two  small  tumors  just  under  the  integu- 
ment on  the  outer  side  of  the  right  thigh,  movable  under 
the  skin,  painless,  and  another  nearer  the  knee,  attached 
to  the  integument,  and  distinctly  fluctuating.  Here 
were,  then,  three  characteristic  stages  in  the  progress  of 
gummy  lesions  of  the  integument.  There  was  a  clear 
history  of  syphilis  irregularly  treated  about  fifteen  years 
previously.  Alleged  occurrence,  four  or  five  years 
previous,,  of  large  sores  with  heavy  black  scabs  upon 
them,  chiefly  on  the  legs  and  arms,  which  were  cured 
by  iodide  or  potassium.  Cicatrices  paler  than  the  sur- 
roundings skin  were  found  corroborating  the  statement, 


164  PRACTICAL   CLINICAL   LESSONS   ON 

This  patient  was  in  low  general  condition  from  dissipa- 
tion, insufficient  nutrition,  and  bad  hygiene.  He  was 
given  nutritious  diet,  with  cod  liver  oil.  A  course  of 
iodide  potassium  with  biniodide  hydrarg.,  the  former 
to  be  gradually  increased  by  the  addition  of  a  gi'ain  at 
a  dose,  taken  largely  diluted  with  milk,  up  to  sixty 
grains.  Under  this  treatment  and  care,  with  local  appli- 
cations of  iodoform  in  powder  to  the  ulcerations, 
marked  improvement  at  once  took  place,  and  in  about 
two  months  healing  of  the  open  lesions  was  com- 
plete, and  the  tumors  were  apparently  absorbed. 

Remarks  on  Case  VI. — As  a  rule,  to  which  excep- 
tions are  rare,  the  ulcerative  forms  of  syphilitic  sequelae 
occur  in  those  cases  which  have  either  been  imperfectly 
treated  or  not  treated  at  all  in  the  early  active  form  of 
the  disease.  It  is  also  true  that,  while  the  gravest  acci- 
dent maj  occur  to  those  who  have  had  the  hghtest 
forms  of  early  manifestations,  the  destructive  sequelae 
are  usually  associated  with  a  history  of  profuse  and  re- 
curring eruptions  in  the  early  stages  of  the  disease. 
It  will  be  found  that  whatever  the  form  or  locality  of 
the  lesion  of  late  syphilis,  the  ability  to  assimilate 
large  doses  of  the  iodide  of  potassium  without  inter- 
fering with  the  digestion,  is  a  guarantee  of  rapid  bene- 
fit from  its  use.  Very  great  care,  then,  is  necessary  to 
introduce  this  potent  remedy  so  gradually  and  so  well 
diluted  with  milk  or  some  agreeable  tonic  diluent,  that 
the  digestive  apparatus  may  be  educated  to  tolerate 
the  drug.  Fortunately,  in  cases  where  it  is  required, 
iodism  rarely  occurs  in  any  troublesome  degree  when 
sufficient  care  has  been  exercised  in  this  respect.  The 
substitution  of  pure  iodine  in  plain  molasses,  or  with 
starch,  has  been  previously  suggested,  when  the  iodide 
of  potassium  is  not  tolerated. 

PSORIASIS   OF  TONGUE,   P^OLLOWING   SYPHILIS. 

Case.  N.  M.  W.;  30.  At  22  had  an  initial  lesion  of 
syphilis,  which  remained  unhealed  under  local  applica- 
tions up  to  the  fourth  month  after  infection.  It  was 
then  excised.     Healing  took  place  by  first  intention; 


SYPHILIS   AND   THE   GENITO-URlNARY    DISEASES.    165 

several  small  mucous  patches  were  then  present  in  the 
mouth  and  on  the  tongue;  the  superficial  lymphatic 
glands  were  enlarged  and  indurated  at  all  usual  locali- 
ties. The  patient  was  put  upon  pil.  duplex  (hjd.  mass. 
2  gr.,  ferri  sulph,  exsic.  i  gr.)  thrice  daily,  and  this 
was  continued,  somewhat  irregularly — omitting  several 
times  for  several  weeks,  whenever  some  tenderness  of 
the  gums  appeared — for  a  year  and  a  half.  No  inter- 
current lesions  during  this  time.  Glands  still  some- 
what enlarged ;  mist,  biniodid.  hyd.  (potas.  lod.  8  grs., 
hyd.  biniodid.  -^q),  a  teaspoonful  as  a  rule  thrice 
daily,  but  not  seldom  neglecting  it,  for  the  following  six 
months,  when  no  further  evidences  of  syphilis  having 
developed — the  patient  in  excellent  health — treatment 
was  suspended.  Not  the  least  sign  of  syphilis  for  the 
next  four  years,  when  slight  soreness  of  the  right  side 
of  the  tongue  appeared,  chiefly  along  the  edge.  This 
was  attributed  to  the  excessive  use  of  cigarettes,  to 
which  the  patient  was  addicted.  On  ceasing  this  there 
was  immediate  improvement  in  regard  to  the  soreness, 
but  a  pale,  thin  pellicle,  appeared  in  two  spots  on  the 
tongue,  about  the  size  of  a  split  pea,  a  thin  film  along 
the  edge,  and  a  patch  of  the  same,  as  large  as  a  dime,  on 
the  inferior  surface  of  the  same  side,  and  all  within  a 
few  days.  The  patient  was  put  again  upon  the  binio- 
dide  m'ixture,  and  took  it  faithfully  for  several  weeks, 
making  appKcations  locally  with  a  saturated  solution  of 
nitrate  of  silver,  every  day  or  two,  without  any  very 
decided  benefit.  In  point  of  fact,  the  spots  on  the 
tongue  became  slightly  elevated  and  whiter,  apparently 
from  accumulated  epithelium,  giving  the  characteristic 
appearance  of  a  simple  psoriasis  of  the  tongue.  An 
application  to  these  spots  with  Paquehn's  gas  cautery, 
the  platinum  point  at  a  white  heat,  was  carefully  made, 
and  the  internal  treatment  continued.  The  result  was 
an  immediate  improvement  in  the  appearance  of  the 
spots,  and  after  the  second  application,  about  a  week 
after  the  first,  the  patches  were  quite  freed  from  the 
pellicle.  The  patch  under  the  tongue  was  then  treated 
in  the  same  manner,  carrying  the  cauterization  as  far  as 
possible  through  the  thickness  of    the  pellicle,  subse- 


l66  PRACTICAL   CLINICAL   LESSONS   ON 

quently  simply  brushing  the  platinum  point  quickly 
over  the  surface.  Altogether,  half-a-dozen  apphcations 
were  made  in  the  course  of  four  weeks,  at  the  end  of 
which  time  there  was  complete  disappearance  of  the 
pellicle,  and  scarcely  a  trace  of  the  lesion  remained. 
The  internal  treatment  was  suspended,  and  at  the  end 
of  three  months,  there  was  no  indication  of  return  of 
trouble. 


Syphilis  and  the  genito-urinary  diseases.  167 


LESSON  XVIII. 

Significance  of  psoriasis  of  the  tongue,  following  syphilis;  often  mistaken 
for  mucous  patches  of  the  active  stage  of  syphilis,  and  when  occurring 
after  the  first  or  second  year,  called  chronic  mucous  patches.  All  lesions 
of  late  syphilis,  of  the  same  significance, as  to  their  contagious  property. 
All  caused  by  accumulations  of  so-called  gummy  material,  or  non-con- 
contagious  lymphatic  matter.  So-called  chronic  mucous  patches  of 
tongue  usually  caused  by  use  of  tobacco.  The  authority  of  M.  Four- 
nier,  favoring  the  view  of  their  capacity  for  contagion.  Case  quoted  by 
him  in  illustration.  Analysis  of  M.  Fournier's  case,  and  arguments  to 
show  its  failure  in  proving  the  inoculability  of  late  chronic  lesions  of 
the  tongue,  and  also  from  Fournier's  work  and  other  valued  authori- 
ties to  show,  that  no  form  of  syphilitic  lesion,  is  contagious  after 
the  fourth  year.  This  position  supported  by  the  teachings  and  experi- 
ence of  M.  Fournier,  in  his  work  on  syphilis  and  marriage.  Marriage 
proper  after  a  certain  period.  Strong  statements  of  M.  Fournier  to 
this  effect.  Syphilis  constitutes  only  a  temporary  bar  to  marriage. 
Fournier  adduces  eighty-seven  cases  in  proof  of  this.  Tertiary 
lesions  shown  not  to  be  capable  of  transmitting  syphilis.  Exceptions 
claimed,  lacking  authentic  proof.  Fournier's  case,  cited  to  prove  infec- 
tion from  lesions  present  after  three  or  four  years,  inadmissible.  An- 
alysis of  evidence.  Case  adduced  in  rebuttal.  Case  cited  to  illustrate 
sources  of  error.  What  is  needed  is  a  guide,  as  to  time,  when  syphilitic 
patient  may  be  considered  free  from  danger  of  communicating  the  dis- 
ease. Facts  and  arguments  to  show  that  this  time,  is  not  necessarily 
more  than  three  or  four  years.  Sources  of  error  in  claiming  infection 
beyond  this  time.     Cases  in  illustration. 

Remarks. — The  foregoing  case  would,  I  think,  be 
best  characterized  as  a  psoriasis,  induced  by  tobacco, 
causing  irritation  of  a  surface  predisposed  to  such 
action,  by  the  previous  occurrence  of  local  syphilitic 
lesions  at  this  vicinity,  during  the  active  period  of  the 
disease.  It  has  been  in  my  experience  to  see  quite  a 
number  of  such  cases,  with  or  without  superficial  ulcera- 
tive lesions,  and  which  had  been  classed,  by  previous 
medical  attendants,  as  chronic  mucous  patches,  with  the 
distinct  understanding  that  they  possessed  the  power  of 
communicating  syphilis.  It  should  be  understood  that 
mucous  patches,  are  simply  papules,  occurring  on  mu- 
cous membrane,  and  cannot  exist  as  specific  lesions 
after  the  active  stage  of  svphilis  has  passed.  It  may,  I 
think,  be    safely  stated,    that,    after    the   third,  and   at 


I68  PRACTICAL  CLINICAL  LESSONS   ON 

farthest  after  the  fourth  year,  lesions  of  the  mouth  of 
whatever  character, — either  superficial  glossitis,  which 
is  recognized  b}^  oval  or  circular,  small  or  large  patches, 
or  tubercles  of  thickened  sub-mucous  cellular  tissue  ;  or 
the  deep  glossitis,  which  causes  a  general  hyperthropic 
thickening, — are  due  to  accumulations  of  gummy  mate- 
rial, so-called;  and,  whether  accompanied  by  ulcera- 
tions, superficial  or  deep,  are  of  the  same  nature  as  all 
the  other  lesions  of  so-called  tertiary  or  late  syphilis, 
which  have  been  incontestably  proven  to  be  free  from 
the  contagium  of  syphilis.  The  occurrence  of  super- 
ficial erosions  of  the  tongue,  from  a  few  to  many  years 
after  the  termination  of  the  active  stage  of  syphilis,  is 
not  infrequent.  The  habitual  excessive  use  of  tobacco, 
has  seemed  to  me  more  likely  to  produce  superficial 
ulcerative  lesions,  than  where  syphilis  has  not  been  ex- 
perienced, especially  where  the  lesions  of  the  active 
disease  have  occurred  in  the  mouth.  Often,  in  such 
cases,  simple  abstinence  from  tobacco,  will  cause  such 
ulcerations  to  heal,  without  further  trouble.  In  other 
cases,  the  iodide  of  potassium  acts  quickly  to  relieve, 
but,  in  all,  the  apprehension  of  communicating  syph- 
ilis is  an  ever-present  horror,  and  when,  as  is  some- 
times the  case,  such  ulcerations,  either  from  vices  in  the 
digestive  processes,  or  from  permanent  cicatricial  dis- 
turbances of  the  affected  tissues,  continue  for  years, 
the  condition  of  such  patients  is  sometimes,  indeed, 
pitiable.  It  is  true  that  we  have  the  weight  of  an 
authority,  so  great  as  M.  Fournier,  in  support  of  the 
possibility,  nay,  the  probability,  of  infection  of  syphi- 
lis for  many  years,  or,  indeed,  indefinitely  in  such 
cases,  as  is  shown  in  the  following,  quoted  from  his 
popular  work  on ''Syphilis  and  Marriage."*  "These 
lesions  are  always  superficial,  limited,  and  mild.  They 
are  readily  cured  by  cauterization,  aided  by  some  local 
care ;  but  they  are  only  cured  to  be  reproduced, — to  re- 
new themselves  incessantly.     In  themselves  they  are  of 

*  "Syphilis  et  Mariag-e."  Legons  Professees  a  I'Hopital  Saint  Louis. 
Par  Alfred  Fournier,  Professeur  a  la  Facuite  de  Medecine  de  Paris, 
Medecin  de  I'Hopital  Saint  Louis,  Membre  de  I'Academie  de  M6decine. 
Paris,  1880.     Page  122. 


SYPHILIS  AND   THE   GENITO-URINARY  DISEASES.    169 

no  importance,  but  they  become  only  the  more  danger- 
ous in  respect  to  contagion.  Such,  for  example,  is  the 
case  of  a  patient  whom  I  treated  some  time  ago.  This 
young  man  had  been  infected  with  a  syphilis,  five  years 
before,  which  one  could  fairly  call  mild,  since  the  initial 
chancre  was  only  followed  by  a  roseola,  a  palmar  syphi- 
lide  of  slight  intensity,  and  a  sore  throat.  He  treated 
it  almost  from  the  beginning  sufficiently  well ;  several 
times  he  submitted,  under  my  advice,  to  a  strong  mer- 
curialization  (15  to  20  centigrammes  of  proto-iodide 
daily).  Well,  in  spite  of  this  treatment,  and  in  spite  of 
all  my  efforts,  the  patient  (who,  by  the  way,  is  a  smoker  : 
a  circumstance  essential  to  note)  has  not  ceased  to  be 
affected,  during  a  period  of  five  years,  with  lingual  syphi- 
hdes  almost  continuously.  I  cured  him  of  one  breaking 
out ;  one  or  two  months  later  a  new  one  attacked  the 
tongue;  then  came  a  new  treatment,  followed  by  a  new 
cure  ;  then  reappearance  of  the  malady,  and  so  on. 
To  be  brief,  I  always  cured  him,  and  '  it  always  began 
again,'  to  use  his  own  expression.  Now  that  he  has 
completely  given  up  tobacco,  at  my  earnest  solicitation, 
the  eruptions  become  less  frequent,  but  have  not  alto- 
gether ceased ;  and  quite  lately  I  have  again  seen  him 
with  syphilis  coming  on  the  back  part  of  his  tongue. 
Now,  what  would  have  happened  if,  relying  on  the 
mild  nature  of  his  disease,  and  satisfied  as  to  the  treat- 
ment followed,  I  had  allowed  the  patient  to  marry  be- 
tween the  two  outbreaks  of  such  symptoms?  What 
would  have  happened,  I  need  not  predict  theoretically, 
because  I  have  had  a  practical  demonstration.  This 
young  man  took  as  a  mistress,  last  year,  a  woman  who, 
till  then,  was  perfectly  healthy  :  exempt  from  every 
venereal  symptom.  Some  weeks  later  he  brought  her 
to  me,  affected  by  an  indurated  labial  chancre,  mani- 
festly received  from  the  lingual  syphilides  of  the 
patient." 

This  case  is  presented  as  a  typical  one,  to  illus- 
trate the  possible  -persistence  of  contagious  lesions 
after  many  years,  notwithstanding  the  disease  is  of 
mild  form,  and  has  been  systematicall}^  persistently, 
and  efficiently  treated  from  **  almost  from  the  begin- 
ning." 


1^0  PkACttCAL  CLINICAL  LESSONS   ON 

It  will  at  once  be  seen,  that,  as  such  lesions  of  the 
mouth  may  appear,  several  years  after  the  apparent 
cure  of  syphilis,  no  real  guarantee  against  the  dan- 
ger of  communicating  syphilis,  for  a  very  long  period 
of  years,  can  ever  be  given,  and  if  such  guarantee  can- 
not be  given,  no  man,  it  appears  to  int\  has  ever  a  right 
to  advise,  or  even  to  consent  to,  marriage  of  a  person 
who  has  once  had  syphilis.  It  becomes  a  matter  of 
vital  importance  to  know,  whether  or  not,  there  is  a 
form  of  late  lesion  of  syphilis,  which,  unlike  all  other 
late  lesions,  still  retains  the  power  of  infection. 
M.  Cornil  says  (p.  34,  Am.  ed.  1882):  ''The  inocula- 
tions made  by  Diday  render  it  probable  that  the  tertiary 
lesions  are  not  inocitlable,  and  consequently  not  contagions^ 
Bumstead  &  Taylor  (ed.,  1879,  P-  443)-  '''Hence  we  con- 
sider the  blood  and  the  secretions  in  tertiary  syphilis  in- 
nocuous'' Hill  &  Cooper  (London,  1881,  p.  11),  say: 
^^  All  attempts  to  propagate  the  disease  zvith  secretions 
taken  at  this  period  have  failed!'  Baumler  says  of  the 
cessation  of  the  innoculable  stage  of  syphilis :  "  This 
takes  place  in  the  majority  of  cases,  and  at  the  expira- 
tion of  eighteen  mo7itJis  or  two  years  the  infection  is  en- 
tirely exhausted."  (Ziemssens's  ''  Encyclop2edia/'  Am. 
edition). 

The  most  complete  and  irrefragable  evidence,  in 
favor  of  the  view  that  the  injective  power  of  syphilis 
is  self-limited,  and  does  not  extend  over  a  period 
of  more  than  three  or  four  years,  is  that  presented 
by  M.  Fournier,  in  his  recent  work  on  "  Syphilis  and 
Marriage,"  adduced  to  justify  his  previous  statement 
of  opinion,  that  persons  having  had  syphilis  under 
certain  circumstances  may  marry.  The  statement,  a 
very  strong  one,  appears  on  page  18  of  his  work,  thus  : 
*'  Then,  yes  ;  a  hundred  times,  yes  :  one  may  marry  after 
having  had  syphilis,  and  the  results  of  such  a  marriage, 
contracted  under  these  conditions,  may  end  absolutely 
happily,  medically  speaking.  This  I  affirm,  and  fear- 
lessly proclaim  from  the  house-tops,  after  having  con- 
cientiously  studied  this  grave  question,  both  clinically 
and  socially,  and  after  having  religiously  consulted  num- 
bers of  observations  of  m}^  own  and  others.  It  is  for 
me  an  absolute  fact,  an  undeniable  truth ;"  and  at  page 


SYPHILIS  AND   THE   GENITO-URINARY   DISEASES.     I^t 

t5,  ibid.:  "The  truth  is  that,  with  some  very  rare  ex- 
ceptions, syphilis  only  constitutes  a  temporary  bar  to 
marriage."  In  support  of  this  positive  opinion  he  says,* 
"  For  my  part  alone,  I  have  in  my  hands,  to  speak  only 
of  written  facts,  eighty-seven  observations  relative  to 
syphilitic  subjects,  undoubtedly  syphilitic,  who,  having 
married,  have  never  conimunicated  to  their  wives  the  least 
suspicious  phenomenon  ;  and,  moreover,  these  eighty-seven 
have  produced  among  them  a  total  of  one  hundred  and 
fifty-six  absolutely  healthy ^  children." 

In  examining  the  clinical  records  of  these  eighty- 
seven  cases,  given  at  page  231,  et  seq.,  of  his  work,  we 
find  that  thirty-six  out  of  this  number  of  men  who  were 
thus  proven  free  from  any  power  to  transmit  syphihs, 
either  by  direct  contact  or  by  heredity,  were  subjects 
of  late  or  tertiary  lesions  of  syphilis  after  marriage — 
some  before  and  some  after  the  birth  of  children. 

These  lesions  comprise  almost  all  the  accidents  of  late 
sj'philis,  thus :  gumma  of  penis,  palmar  psoriasis,  dry 
tubercular  syphilide,  gumma  of  velum  paluli,  cerebral 
syphilis,  papulo-tubercular  syphilide,  and  costal  perios- 
tosis,  cerebro-spinal  symptoms  (evidently  of  specific 
origin),  diplopia,  passing  attacks  of  hemiplegia,  nasal 
<yphilides,  ecthyma  of  legs,  specific  tibial  periostitis 
and  glossitis,  specific  sarcocelele,  nasal  ulcers,  ulcerative 
laryngitis,  papulo-squamous  palmar  and  plantar  syphili- 
des,  sclerous  glossitis,  papulo-scabby  syphihdes  of  cir- 
cinate  form,  tubercular  ulceration,  syphiUde  of  nose. 

This  would  appear  to  be  sufficient  evidence  that  M. 
Fournier,  presenting  these  cases  to  show  that  they  lacked 
entirely  the  contagious  element,  was  a  firm  believer  in 
the  non-transmissibility  of  syphilis  from  late  lesions. 

Another  case,  quite  in  line  of  the  first  case  cited — which 
seemed  to  prove  indefinite  capacitv  for  infection,  appears 
inadvertentlv  to  have  slipped  into  INI.  Fournier's  87  cases. 
This  is  Case  XLIX.  (p.  237  ibid.).  Thus  runs  the  clinical 
history  :  "  Hard  chancre,  roseola  palmar,  psoriasis,  syph- 
ilides  of  the  mouth ;  iodide  treatment ;  no  mercury. 
Married  four  years  after  infection  ;  wife  remained  free  ; 

'••  Fournier,  "  Syphillis  et  Mariac;e."     Ibid.,  p.  l6,  also  p.  231. 


172  PRACTICAL  CLINICAL  LESSONS  ON 

two  healthy  children.  After  the  birth  of  the  second  child 
the  husband  infected  the  wife  through  a  syphilide  of  the 
mouth  ;  pregnancy  the  following  year  ^  which  ended  in  a  mis- 
carriage  r 

Lacking-  any  other  explanation  from  M.  Fournier, 
this  case  would,  then,  appear  to  be,  like  the  first  case  pre- 
sented, one  where  a  late  lesion  of  the  mouth  had  com- 
municated syphilis,  and  this  at  least  seven  years  after 
the  original  infection,  and  even  after  several  years  of 
marriage,  during  which  the  wife  had  escaped,  and  two 
healthy  children  had  been  born.  Exceptions  of  such 
vital  importance — the  first  cited  as  a  typical  exception, 
and  the  second  supporting  it  with  great  force — in  or- 
der to  be  accepted,  should,  it  appears  to  me,  be  quite 
free  from  reasonable  doubt,  on  all  essential  points.  Let 
us  examine  them  as  critically  as  these  meagre  details  will 
permit. 

In  the  first  case,  after  a  mild  and  thoroughly  treated 
syphilis,  in  a  patient  who  was  an  inveterate  smoker,  les- 
ions of  the  mouth  recurred  constantly,  for  a  period  of 
five  years,  influenced  only  temporarily  by  treatment — 
promptly  benefited  by  leaving  off  his  tobacco.  Phj^sician 
(M.  Fournier)  fears  that  this  lesion  is  an  exception  to 
the  lesions  of  syphilis  which  occur  at  so  late  a  period. 

M.  Fournier's  experience  in  regard  to  inoculability, 
at  so  late  a  period,  are  given  in  his  work,  as  at  p.  loi, 
where  he  says:  *' In  those  cases  where  I  have  seen 
syphilis  pass  directly  from  the  father  to  the  child, 
without  contamination  of  the  mother,  I  have  always  ob- 
served, that  the  paternal  infection,  was  of  a  comparatively 
recent  date,  that  is  to  say,  had  not  exceeded  the  maxi- 
mum of  three  or  four  years.  Beyond  that  time  I  have 
never  firmly  established  the  transmission  of  syphilis  by 
paternal  heredit-.y."*  Again  at  page  132:  "A  patient 
comes  to  us  in  the  full  secondary  period,  and  we  submit 
him  to  the  usual  treatment.  Now,  what  occurs,  nineteen 
times  out  of  twenty  at  least?  First,  that  the  patient  is 
subjected  for  some  months — even  for  the  first  year — to 
secondary  eruptions,  more  or  less  numerous,  more  or  less 

*  Italics  my  own.     F.  N.  O. 


SYPHILIS  AND   THE   GENITO-URINARY   DISEASES.    173 

intense,  corresponding  to  the  quality  of  the  diathesis, 
but  generally  mitigated  and  lessened  by  treatment.  And 
beyond — from  about  the  second  year — these  eruptions 
continue  to  decrease  .  .  .  Then,  still  later,  the  lessening 
is  more  marked,  or  becomes  complete  with  the  third,  or, 
later,with  the  fourth  year.  From  that  time,  the  secondary 
period  is  done,  and,  with  it,  the  contagious  accidents 
which  accompany  it,  and  which  constitute  the  principal 
dangers  of  marriage.  Such  is  the  rule :  that  this  rule 
has  exceptions  I  know  but  only  too  well;  and  I  have 
already  given  examples  of  such  exceptions"  (p.  122  ibid.), 
[case  above  cited].  In  this  case  a  young  man  takes  a 
mistress,  who  some  weeks  later  presents  with  an  initial 
lesion  of  the  lip.  The  conclusion  appears  to  have  been 
promptly  arrived  at  on  the  following  basis,  viz.:  possi- 
bility oi  contagion  from  patient's  buccal  erosions,  (which 
did  not  yield  to  anti-syphilitic  treatment,  but  which  did 
improve  when  tobacco  w^as  withheld) ;  probability  that 
the  mistress  acquired  her  labial  chancre  from  the  secre- 
tion of  this  very  exceptional  kind  of  syphilitic  lesion,  if 
it  was  syphilitic. 

Now,  is  such  a  conclusion  sufficiently  warranted  by 
this  evidence,  on  a  matter  of  such  moment  ?  Let  us  look 
at  other  causes,  equally  possible,  equally  probable.  The 
young  man  did  not  take  for  a  mistress,  a  woman  whose 
virtue  was  above  suspicion.  Such  a  coincidence  as 
the  contact  of  such  a  woman's  lip,  with  some  other  Hp, 
with  fresher  syphihtic  lesions,  would  not  be  so  extraordi- 
nary, as  the  acquirement  of  syphilis,  from  a  buccal  \qs- 
lOUy  five  years  after  infection.  Such  a  woman,  would  be 
quite  in  line  of  coming  in  contact  with  persons  having 
active  syphilis,  and,  either  directly  or  by  mediate  con- 
tagion, might  have  acquired  her  labial  chancre,  even  if 
she  had  not  become  this  man's  mistress,  without  exciting 
especial  comment. 

Let  me  here  place  in  contrast  to  this,  a  case  taken 
from  my  own  experience.  A  young  man  had  undoubted 
syphilis — characteristic  initial  lesion,  general  gland  en- 
largement, roseola;  no  pronounced  papular  eruption; 
mucous  patches  on  tongue  and  inner  surface  of  cheeks. 
After  a  somewhat  desultory  treatment  of  two  years, 


174  PRACTICAL  CLINICAL   LESSONS   ON 

he  was  apparently  cured.  Remained  well  for  two 
years;  began  to  have  ulcerations  at  side  of  tongue,  thin 
pearl-colored  at  edges;  characteristic  appearance  of 
the  so-called  chronic  mucous  patch ;  was  greatly  ad- 
dicted to  tobacco — tongue  resisted  local  treatment, 
unless  accompanied  by  exclusion  of  tobacco ;  repeated 
recurrences  for  nearly  five  years  ;  not  markedly  affected 
by  specific  treatment,  which  was  tried  from  time  to 
time.  At  last  he  married  a  virtuous  girl,  since  when 
already  two  years  have  elapsed,  and  she  has  not  yet  ac- 
quired syphilis. 

In  regard  to  M.  Fournier's  second  case:  this  is  ren- 
dered especially  remarkable,  by  the  fact,  that,  besides  the 
alleged  acquirement  of  syphilis,  by  the  wife,  from  a  buc- 
cal syphilide  in  the  husband  seven  years  after  infection, 
that  without  any  specific  treatment,  the  wife  remained 
free  from  syphilis  during  the  early  years  of  marriage, 
and,  besides,  gave  birth  to  two  healthy  children  during 
this  period.  The  acquirement  of  syphilis,  from  other 
and  unsuspected  source,  would  be  much  more  in  accord- 
ance with  the  probabilities  of  this  case,  than  that  this 
most  extraordinary  development  of  active  syphilis,  upon 
a  diathesis  which  had  slumbered  through  the  initiation 
and  development  of  two  healthy  children,  should  break 
out  finally  in  infective  buccal  lesion.  The  theory  of 
re-acquirement  of  syphilis,  from  a  fresh  source,  is  not  so 
difficult  to  accept. 

The  experience  and  teaching  of  all  the  leading  author- 
ities, to-day,  are  against  the  acceptance  of  any  claim  for 
inoculability  of  the  secretions  of  syphilitic  sequelae,  and 
any  cases,  militating  against  this  view,  should  be  free 
from  suspicion  of  imperfect  observation,  imperfect 
facilities  for  observation,  and  from  conclusions  not  based 
upon  thoroughly  well-authenticated  facts. 

Case  —  on  page^'^vill  show  how  easily  active  syphi- 
lis in  a  wife  may  appear  to  have  been  acquired  from  a 
husband  who  had  had  syphiUs  many  3^ears  previously — 
and  yet,  against  all  presumtive  evidence,  she  may  be  final- 
ly shown  to  have  acquired  the  disease  in  a  manner  more 
in  accordance  with  all  that  is  now  positively  known  of 
the  disease.    The  evidence  in  favor  of  the  innocence  of 


SYPHILIS  AND   THE   GENITO-URINARY  DISEASES.    1 75 

M.  Fournier's  females  was  no  greater  than  in  my  case,  and 
yet  the  latter  was  proven  guilty  out  of  her  own  mouth. 
What  the  profession  needs  now,  more  than  anything 
else,  is  some  rehable  guide  towards  the  formation  of  an 
opinion,  as  to  the  time  it  is  necessary  to  treat  S3^philis, 
before  the  patient  may  be  considered  free  from  the  dan- 
ger of  communicating  the  disease  to  others.  It  would 
seem  probable,  that  an  explanation  of  the  course  pur- 
sued in  M.  Fournier's  87  cases  might  afford  light  on  this 
matter.  In  point  of  time  we  find  that  the  average  time 
of  marriage  in  the  87  cases  was  $-^q  years,  that  25  per 
cent  were  married  within  three  years  after  infection, 
and  over  10  per  cent  within  two  years.  In  regard  to  the 
length  and  quality  of  treatment:  over  12  per  cent  of 
the  87  cases  had  a  treatment  of  less  than  a  year's  dura- 
tion, several  with  only  a  few  months,  one  with  the 
iodide  of  potass,  only,  and  another  with  no  treatment  at 
all  (marriage  seven  years  after  infection).  It  would  ap- 
pear, then,  that  the  contagious  element  of  syphilis  is  not 
necessarily  dependent  upon  treatment  for  its  eradication. 
This  would  confirm  the  claim  made  in  the  earlier  pages 
of  this  work,  that  syphilis,  in  its  contagious  phase,  is  self- 
limited,  and  that  the  value  of  a  prolonged  and  systematic 
treatment,  consists  chiefly,  in  its  power  to  prevent  that 
damage  to  the  tissues  and  organs  of  the  body,  which  may 
finally  eventuate  in  important  lesions  in  after  years,  viz., 
the  seqiielcB  of  syphilis  in  their  various  forms.  The 
time  during  which  the  treatment  should  be  continued 
should  certainly  cover  all  that  period,  during  which  the 
affected  organism  contains  any  contagious  element. 
This  question  must  be  settled  by  clinical  observation. 
If  we  find  that  there  are  well-authenticated  cases  of 
communication  of  the  disease,  after  many  y QdiVS,  without 
re-infection,'^  and  that  we  cannot  tell  by  the  degree  or 
quality  of  the  syphilis,  what  cases  may  behave  in  this 
manner,  we  are  then  assuming  unwarranted  responsi- 
bility, in  allowing  any  persons  with  syphilitic  antecedents 
to  marry.     If,  however,  we  can   find  by  strict  scrutiny 

*  For  facts  and  arguments  showing  that  re-infection  of  syphilis  is  not 
infrequent,  see  Cornil  on  Syphilis,  Am.  ed. :  Henry  C.  Lea's  Son,  Phil., 
1882,  p.  19. 


178  PRACTICAL  CLINICAL  LESSONS  ON 

least,  that  the  subject  of  syphilis,  might,  within  a  reason- 
able  number  of  years — say  three  or  four,  or  even  five — at 
least,  resume  his  ordinary  association  with  his  kind, 
without  the  ever-present  dread  of  communicating  syphi- 
lis, from  an  ever  possibly  recurring,  periodically  active, 
mucous  patch.  Prolonged  existence  of  the  contagious 
element  in  the  seminal  fluid,  though  a  series  of  years, 
has  been  claimed,  and  instances  have  been  cited,  with 
great  appearance  of  truth.  M.  Fournier  quotes  one  re- 
lated by  M.  Jonathan  Hutchinson:  "Thus  a  medical 
man  contracted  syphilis  and  for  about  six  months  treated 
himself.  Believing  himself  cured  and  being  relieved  of 
all  pain,  three  or  four  years  later  he  married.  His  wife 
remained  healthy^  and  became  enciente  eleven  times. 
First  pregnancy,  child  born  dead  ;  second  pregnancy, 
child. born  dead;  third  pregnancy,  child  born  ahve,  but 
syphilitic,  and  dying  with  the  usual  symptons  of  here- 
ditary syphilis  ;  fourth  pregnancy,  child  born  living,  but 
syphilitic  and  dying  also  with  syphilis.  On  the  con- 
trary, the  seven  last  children,  although  born  syphilitic, 
resisted  the  disease  and  lived." 

Here  is  a  case  of  a  healthy  woman,  giving  birth  to  a 
series  of  children  claimed  to  be  syphilitic.  In  order  to 
make  this  case  of  value,  the  evidence  must  be  fuller  and 
more  exphcit.  The  simple  death  of  the  child,  is  not 
sufficient  evidence  of  syphilis ;  repeated  miscarriages 
are  not  necessarily  from  syphilitic  influence;  and  incase 
of  the  third  and  fourth  children,  we  are  not  informed  as 
to  exactly  what  constituted  the  evidences  of  hereditary 
syphilis.  Various  forms  of  imperfect  development,  and 
apparent  disease  of  the  foetus,  result  from  scrofulous  taint, 
from  hereditary  diseases  not  syphihtic,  and  from  disease 
of  and  impressions  on  the  female  generative  organs,  and 
these  propagated  through  successive  pregnancies.  Erup- 
tions, termed  scrofulides,  occur  in  the  newly-born  that 
are,  sometimes,  absolutely  identical  in  appearance  with 
those  of  syphilis.  Cases  of  the  character  of  the  fore- 
going, may  be  true  as  far  as  the  attainable  evidence  goes, 
but  they  must  remain  as  doubtful,  when  the  history  is 
imperfect — because  they  are  opposed  to  all  that  is 
known,  with  any  certainty,  of  the  nature  of  the  disease, 


SYPHILIS  AND   THE   GENITO-URINARY   DISEASES.    1 79 

The  man,  after  four  or  five  years,  with  no  appreciable 
disease,  infects  children,  while  the  mother  reinains  healthy. 
According  to  the  results  of  M.  Mireur's  experiments  in 
inoculating  healthy  subjects,  with  the  semen  of  syphilitic 
men,  in  the  active  stage  of  the  disease,  the  semeji  does 
not  possess  the  contagions  property.  M.  Fournier  says, 
(*'  Syphilis  et  Mariage,"  p.  26,  note) : 

''it  has  long  since  been  established  that  the  semen  of  a 
syphilitic  subject  is  not  susceptible  of  transmitting  contagion!' 
If  this  be  the  fact,  how,  then,  could  the  children  be  con- 
taminated by  the  husband,  independently  of  any  disease 
of  the  wife — who,  it  is  claimed,  remained  healthy  ?  It  is 
certainly  the  fact,  that,  with  the  exception  of  some  rare 
and  anomalous  cases  (such  as  the  one  quoted),  the  weight 
of  the  evidence  of  every  authority  has  been  given,  in 
favor  of  a  gradual  diminution  of  the  contagious  element 
in  syphilis,  and  its  complete  disappearance  within  three 
or  four  years.  Under  the  influence  of  the  old  views 
that  the  later  lesions — the  sequelae — were  also  capable  of 
transmitting  syphilis,  it  was  difficult  to  set  a  limit  to 
the  time,  when  a  man  could  be  said  to  be  free  from  dan- 
ger of  communicating  the  disease,  but  as  it  has  now  been 
satisfactorily  proved,  that  the  active  stage  of  the  disease, 
does  not  as  a  rule  exist  more  than  three  or  four  years, 
and  that  the  secretions  of  the  sequelae  and  the  blood  are 
free  from  the  contagious  element,  apparent  exceptions  to 
this  law  must  be  accepted  as  proved,  only  after  the  most 
rigid  scrutiny,  and  refused  admission,  except  on  absolute 
proof. 

Note. — In  the  spring  of  i860,  and  thus  over  twenty 
years  ago,  I  was  called  to  see  an  infant  about  a  year 
old,  the  daughter  of  a  prominent  merchant,  a  most  up- 
right and  religious  man.  The  child  had  been  vaccinated 
some  three  months  previously  without  any  unusual  local 
result.  About  a  month  afterward  a  rose-colored  erup- 
tion made  its  appearance,  and,  while  fading  somewhat,  it 
remained,  and  began  to  create  some  apprehension  lest 
it  had  resulted  from  an  impure  vaccine  virus.  When  I 
saw  the  child,  the  eruption  was  exactly  like  that  of  a  fad- 
ing syphilitic  roseola,  slightly  red,  and  inclining  to  a  cop- 
pery hue,  chiefly  well-marked  on  forehead  and  cheeks- 


1 78  PRACTICAL  CLINICAL  LESSONS  ON 

least,  that  the  subject  of  syphilis,  might,  within  a  reason- 
able  number  of  years — say  three  or  four,  or  even  five — at 
least,  resume  his  ordinary  association  with  his  kind, 
without  the  ever-present  dread  of  communicating  syphi- 
lis, from  an  ever  possibly  recurring,  periodically  active, 
mucous  patch.  Prolonged  existence  of  the  contagious 
element  in  the  seminal  fluid,  though  a  series  of  years, 
has  been  claimed,  and  instances  have  been  cited,  with 
great  appearance  of  truth.  M.  Fournier  quotes  one  re- 
lated by  M.  Jonathan  Hutchinson:  ''Thus  a  medical 
man  contracted  syphilis  and  for  about  six  months  treated 
himself.  Believing  himself  cured  and  being  relieved  of 
all  pain,  three  or  four  years  later  he  married.  His  wife 
remained  healthy,  and  became  e7iciente  eleven  times. 
First  pregnancy,  child  born  dead ;  second  pregnancy, 
child  born  dead;  third  pregnancy,  child  born  ahve,  but 
syphilitic,  and  dying  with  the  usual  symptons  of  here- 
ditary syphiUs;  fourth  pregnancy,  child  born  living,  but 
syphilitic  and  dying  also  with  syphilis.  On  the  con- 
trary, the  seven  last  children,  although  born  syphilitic, 
resisted  the  disease  and  lived." 

Here  is  a  case  of  a  healthy  woman,  giving  birth  to  a 
series  of  children  claimed  to  be  syphihtic.  In  order  to 
make  this  case  of  value,  the  evidence  must  be  fuller  and 
more  explicit.  The  simple  death  of  the  child,  is  not 
sufficient  evidence  of  syphilis ;  repeated  miscarriages 
are  not  necessarily  from  syphilitic  influence;  and  incase 
of  the  third  and  fourth  children,  we  are  not  informed  as 
to  exactly  what  constituted  the  evidences  of  hereditary 
syphilis.  Various  forms  of  imperfect  development,  and 
apparent  disease  of  the  foetus,  result  from  scrofulous  taint, 
from  hereditary  diseases  not  syphilitic,  and  from  disease 
of  and  impressions  on  the  female  generative  organs,  and 
these  propagated  through  successive  pregnancies.  Erup- 
tions, termed  scrofidides,  occur  in  the  newly-born  that 
are,  sometimes,  absolutely  identical  in  appearance  with 
those  of  syphilis.  Cases  of  the  character  of  the  fore- 
going, may  be  true  as  far  as  the  attainable  evidence  goes, 
but  they  must  remain  as  doubtful,  when  the  history  is 
imperfect — because  they  are  opposed  to  all  that  is 
known,  with  any  certainty,  of  the  nature  of  the  disease, 


SYPHILIS  AND   THE   GENITO-URINARY  DISEASES.    1 79 

The  man,  after  four  or  five  years,  with  no  appreciable 
disease,  infects  children,  while  the  mother  reinains  healthy 
According  to  the  results  of  M.  Mireur's  experiments  in 
moculating  healthy  subjects,  with  the  semen  of  syphilitic 
men,  in  the  active  stage  of  the  disease,  the  semen  does 
not  possess  the  coyitagious  property.  M.  Fournier  says, 
C'  Syphilis  et  Mariage,"  p.  26,  note) : 

"It  has  long  since  been  established  that  the  semen  of  a 
f?^  u  f  ^^^^-^^"^^  ^^  ^^^^  susceptible  of  transmitting  contagionr 
It  this  be  the  fact,  how,  then,  could  the  children  be  con- 
taminated by  the  husband,  independently  of  any  disease 
of  the  wife— who,  it  is  claimed,  remained  healthy  ?  It  is 
certainly  the  fact,  that,  with  the  exception  of  some  rare 
and  anomalous  cases  (such  as  the  one  quoted),  the  weight 
of  the  evidence  of  every  authority  has  been  given  in 
favor  of  a  gradual  diminution  of  the  contagious  element 
in  syphilis,  and  its  complete  disappearance  within  three 
or  four  years.  Under  the  influence  of  the  old  views 
that  the  later  lesions— the  sequels— were  also  capable  of 
transmitting  syphilis,  it  was  difficult  to  set  a  limit  to 
the  time,  when  a  man  could  be  said  to  be  free  from  dan- 
ger of  communicating  the  disease,  but  as  it  has  now  been 
satisfactorily  proved,  that  the  active  stage  of  the  disease 
does  not  as  a  rule  exist  more  than  three  or  four  years' 
and  that  the  secretions  of  the  sequelae  and  the  blood  are 
tree  from  the  contagious  element,  apparent  exceptions  to 
this  law  must  be  accepted  as  proved,  only  after  the  most 
rigid  scrutiny,  and  refused  admission,  except  on  absolute 
proof. 

Note.— In  the  spring  of  i860,  and  thus  over  twenty 
years  ago,  I  was  called  to  see  an  infant  about  a  year 
old  the  daughter  of  a  prominent  merchant,  a  most  up- 
right and  religious  man.  The  child  had  been  vaccinated 
some  three  months  previously  without  any  unusual  local 
result.  About  a  month  afterward  a  rose-colored  erup- 
tion made  its  appearance,  and,  while  fading  somewhat,  it 
remained,  and  began  to  create  some  apprehension  lest 
it  had  resulted  from  an  impure  vaccine  virus.  When  I 
saw  the  child,  the  eruption  was  exactly  like  that  of  a  fad- 
ing syphilitic  roseola,  slightly  red,  and  inclining  to  a  cop- 
pery hue,  chiefly  well-marked  on  forehead  and  cheeks- 


l8o  PRACTICAL  CLINICAL  LESSONS   ON 

breast  back  and  abdomen.  The  date  of  its  appearance, 
following-  vaccination,  suggested  syphilis,  also  its  color, 
first  rosy,  then  inclining  to  a  coppery  hue.  I  communi- 
cated my  suspicion  to  the  father  and  at  the  same  time 
inquired  into  his  venereal  antecedents.  He  acknowl- 
edged to  a  gonorrhoea  in  early  youth,  which  had  caused 
him  much  remorse,  but  he  denied  knowledge  of  any  syph- 
ilitic lesion.  The  wife  was  apparently  in  good  health. 
There  were  three  health}^  children  older  than  the  little 
girl.  The  physician  who  performed  the  vaccination, 
stated  its  source,  which  was  unobjectionable,  and  stated, 
also,  that  he  had  vaccinated  at  least  a  dozen  children 
with  the  same  virus  as  that  used  on  this  little  patient, 
without  any  sign  of  such  trouble  following.  Having- 
scarcely  a  doubt  of  the  syphihtic  character  of  the  erup- 
tion, I  put  the  child  on  a  systematic  mercurial  treatment ; 
this  was  continued  for  six  months,  without  any  especial 
change.  I  then  called  in  the  late  Dr.  Bumstead,  (my 
predecessor  in  the  Chair  of  Venereal  Diseases  in  the  Col- 
lege of  Physicians  and  Surgeons,  N.  Y.)  in  consultation. 
My  previous  diagnosis  was  confirmed,  unhesitatingly, 
and,  for  another  six  months,  the  same  treatment  was  con- 
tinued. Not  3^et  making  any  impression  on  the  eruption 
— the  child  otherwise  in  excellent  condition — Dr.VVm.  H. 
Draper,  who  then  occupied  the  Chair  of  Cutaneous  Dis- 
eases in  the  College  of  Physicians  and  Surgeons,  was  then 
called  in  consultation.  The  case  was  accepted  as  most 
singular,  but  previous  diagnosis,  after  careful  considera- 
tion,was  again  confirmed,  and,  for  another  six  months,  the 
treatment  was  rigidly  enforced,  at  the  end  of  which  time 
I  took  the  responsibility  of  stopping  the  mercurial,  as,  up 
to  that  time,  apparently,  no  benefit  had  accrued  from  its 
use.  I  then  tried  a  mild  arsenical  preparation  for  a  few- 
months, -with  equal  ill  success,the  eruption  still  remaining 
distinct  and  coppery  in  all  regions  previously  occupied 
by  it.  During  the  next  ten  years  the  child  grew  fairly 
well.  She  was  somewhat  delicate,  and  of  a  nervous,  lym- 
phatic temperament,  and  occasionally  received  a  httle 
aid  to  her  nutrition,  such  as  might  be  afforded  by  extract 
of  malt,  cod  liver  oil,  etc.  My  attention  at  this  time 
(when  the  child  was  now  over  twelve  years  of  agej  was 


SYPHILIS   AND   THE    GENITO-URINARY   DISEASES.    l8l 

called  to  several  exostoses  on  the  radius  and  ulna,  both 
at  the  distal  and  proximal  extremites  on  the  inner  aspect, 
also  on  the  outer  and  inner  sides  of  the  head  of  the  tibise. 
This  seemed  to  confirm  the  original  diagnosis,  which  I 
had  long  previously  abandoned.  1  was  contemplating 
a  renewal  of  the  treatment,  adapted  to  the  later  stage  of 
syphilis,  when  it  occured  to  me  to  call  in  Dr.  A.  Jacobi, 
then  Professor  of  the  Diseases  of  Children  of  the  College 
of  Physicians  and  Surgeons.  The  eruption  was  some- 
what faded,  but  still  distinct,  on  the  cheeks,  forehead,  and 
breast,  especially  well-marked  during  any  excitement, 
mental  or  physical.  Professor  Jacobi  expressed  an 
opinion  against  the  idea  of  syphilis,  and  considered  the 
eruption  a  scrofulide,  and  the  exostoses  rachitic.  This 
fully  explained  the  anomalous  case  of  syphilis,  as  it  had 
been  supposed  to  be,  and  was  then  accepted,  as  rachitic, 
and  was  subsequently  treated  by  me,  in  accordance  with 
this  view.  The  family  leaving  New  York,  soon  after 
went  to  reside  in  a  neighboring  city.  Here,  after  con- 
sultation with  the  new  family  physician,  the  patient 
underwent  another  course  of  mercury,  and  this  time 
with  iodide  of  potassium  for  many  months,  and  finally, 
having  about  a  year  since  become  quite  lame  from 
the  growth  of  the  extoses,  and  their  interference  wdth 
muscular  action,  a  distinguished  surgeon  from  New 
York  was  called  in  consultation,  to  see  if  any  sur- 
gical aid  could  be  afforded.  A  brother  of  the  patient 
called  on  me  a  few  months  since  to  say  that  my  old 
view  of  the  case  had  turned  out  to  be  correct,  and  that 
no  surgical  aid  was  thought  advisable,  but  the  young 
lady  had  been  put  on  a  thorough  course  of  mercury  and  the 
iodide  of  potassium!'  During  the  several  years  which  had 
intervened,  since  the  case  had  been  previously  con- 
sidered one  of  syphilis,  the  change  of  opinion  had  been 
lost  sight  of.  Meeting  the  surgeon  soon  after  his 
examination  of  the  case,  I  recited  the  patient's  former 
history  which  had  not  been  made  at  all  clear  in  the  later 
consultations ;  since  this  time  I  have  had  reason  to  be- 
lieve that  the  anti-syphilitic  treatment  has  been  again 
suspended. 

The  father  of  the  young  lady  whose  history  has  been 


1 82  PRACtlCAL  CLINICAL  LESSONS   ON 

given  above — after  apparent  proof  that  the  vaccination 
was  not  at  fault — became  morbidly  remorseful  on  ac- 
count of  his  early  gonorrhoea.  The  later  consultations 
were  influenced,  by  a  statement  of  the  sons,  that  their 
father,  just  before  his  death,  some  3^ears  before,  had  given 
them  to  understand,  that  he  had  transmitted  the  disease 
to  their  sister  through  a  youthful  folly. 

It  may  be  safely  stated  that  the  diagnosis  of  syphilis  has 
often  been  made,  on  much  more  slender  ground  than  in 
the  foregoing  case,  and  the  source  of  infection  accepted, 
not  because  there  was  any  reasonable  proof,  but  because 
it  was  not  positively  accounted  for  in  any  other  way. 
The  mere  suspicion  of  an  attack  of  syphilis  in  a  man's 
youth,  in  the  minds  of  many  ph3^sicians,  appears  to  war- 
rant the  assumption  of  an  ever-present  contagious  ele- 
ment, and  to  account  for  any  and  every  obscure  trouble, 
which  may  afflict  himself,  his  wife,  or  his  children,  to 
the  end  of  life. 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.    183 


LESSON  XIX. 

GUMMY  TUMOR   OF   BONE — LOSS    OF    SUBSTANCE    WITH- 
OUT  CARIES. 

Clinical  case  in  illustration.  Facts  showing  that  the  disease  is  local  in 
its  nature.  The  dry  caries  of  Virchow  due,  like  all  tertiary  lesions  of 
syphilis,  to  mechanical  causes.  No  contagium  ever  discovered  in  them. 
Lesions  like  those  in  case  cited  due  to  pressure  from  accumulation  of 
lymphatic  material.  Similarity  between  the  behavior  of  so-called  dry 
caries  and  the  tubercular  syphilide.  Van  Buren  and  Keyes's  explana- 
tion of  the  latter.  Clinical  case  illustrative  of  ihe  lesion  termed  Syph- 
ilitic Dactylitis.  Behavior  of  this  lesion  shown  to  be  identical  with 
that  of  the  so  called  dry  caries,  and  due  to  similar  causes. 

CaseVII.  B.  W.  F.  ;  aged  70;  merchant.  General 
health  always  g-ood.  Came  complaining  of  the  annoy- 
ance caused  by  two  painless  ulcers,  about  the  size  of 
a  quarter-dollar,  just  above  each  frontal  prominence. 
The  edges  were  abrupt  and  sharp  ;  the  entire  integument 
was  penetrated,  and  the  floor  of  the  ulcers  was  covered 
with  large  florid  granulations.  These  lesions  were  said 
to  have  appeared  about  six  months  previously,  very  soon 
attaining  their  present  dimensions,  and  continuing  quite 
stationary,  in  spite  of  many  sorts  of  local  application 
recommended  by  the  family  physician.  As  the  patient's 
general  health  was  perfect,  no  internal  treatment  had 
been  resorted  to.  The  gentleman  was  quite  bald,  and  on 
examination,  several  depressed  portions  of  the  scalp 
were  recognized,  of  about  the  same  dimensions  as  the 
ulcers.  It  was  evident,  to  the  touch,  that  there  had 
been  a  distinct  sinking  of  the  bone.  This  was  uniform 
and  to  the  depth  of  about  one  line;  the  scalp  was 
smooth  and  movable  at  these  points.  In  point  of  fact, 
the  evidence  of  a  former,  so-called,  dry  caries,  was  in- 
contestable. All  had  occurred  within  the  year,  or  rather 
they  had  only  attracted  attention  during  that  time. 
Throughout  their  course  were  not  recognizable  by  the 
patient,  from  any  discomfort  or  sensation  of  any  sort 
experienced  by  him.  A  course  of  potass,  iodide  and 
biniodid.  hyd.  (mist,  biniodid.  hydrarg.)  was  prescribed, 


184  PRACTICAL  CLINICAL  LESSONS  ON 

under  which,  within  the  following  month,  the  soreis 
healed  perfectly,  with  a  firm  cicatrix,  scarcely  at  all 
depressed. 

Remarks.— T\i^  foregoing  case  has  an  special  value, 
in  the  fact,  that  the  bone  lesion,  the  ''  dry  caries"  of 
Virchow,  is  specific ;  that  is  to  say,  it  is  seen  only  as  a 
sequel  of  syphilis,  and  is  reliably  diagnostic  of  that 
disease.  Furthermore,  it  enables  us  to  understand, 
better  than  any  other  sequel  of  syphilis,  that  the  pro- 
cesses which  result  in  destruction  of  tissue,  of  every 
variety  of  tertiary  lesion  or  sequelse,  are  not  due  to  any 
destructive  principle,  or  virus,  circulating  in  the  blood, 
but  are  due  to  mechanical  obstructions  of  lymph  vesr 
sels,  through  damage  to  such  vessels  or  channels,  during 
the  early  active  stages  of  the  disease.  It  is  conceded 
by  all  scientific  authority,  that  the  late  lesions,  the  seque- 
lse of  syphilis,  without  exception,  are  characterized  by 
a  localized  accumulation  of  the  so-called  gummy  mate- 
rial. It  is  found  in  every  so-called  tertiary  lesion,  and 
in  amount,  sufficient  to  account  for  the  damage  associ- 
ated with  it,  on  purely  mechanical  principles.  Pressure 
on  vessels  of  nutrition  results  in  loss  of  tissue  through 
fatty  degeneration,  locally  and  in  the  parts  distant,  to 
which  such  vessels  are  distributed,  obstruction  of  the 
adventitia  of  blood-vessels,  resulting  in  pressure  upon 
such  vessels,  is  recognized  as  a  cause  of  obliteration  of 
their  lumen.  This  gummy  material  has  been  proved 
not  to  differ,  in  the  least  degree,  from  accumulated 
normal  lymphatic  material.  No  contagium  of  syph- 
ilis has  ever  been  detected  in  it.  In  the  tubercular 
eruption  this  accumulation  of  gummous  material,  so 
called,  is  often  absorbed,  leaving  cicatricial  depres- 
sions, which  are  characteristic,  without  suppuration. 
It  is  recognized  as  resulting  from  pressure  upon  the 
tissue  into  which  it  is  infiltrated,  or  in  which  it  accu- 
mulates, causing  absorption  of  the  tissue.  When  the 
gummy  material  is  taken  up,  the  cicatricial  depres- 
sions result.^    Applying  the  same  explanation  to  lesions 

*  "  The  syphilitic  tubercle  is  due  to  a  diffuse  hyperplasia  of  small 
cells  in  the  substance  of  the  true  skin.  These  cells,  which  partake  of  the 
nature   of  the  so-called  gummy  exudation,  grow  at   the  expense  of  the 


SYPHILIS  AND  THE   GENITO-URINARY  DISEASES.    185 

of  bone,  like  those  designated  the  dry  caries  of  syphilis,  it 
will  be  seen  that  gummy  accumulations  in  bone  may 
follow  the  same  course,  and  that  the  so-called  dry  caries 
is  not  a  true  caries  at  all,  for  there  can  never  be  caries 
without  suppuration.  The  fact  becomes  evident,  that 
the  loss  of  bony  material,  which  results  in  the  depres- 
sion, is  caused  through  absorption  of  the  bony  material 
through  pressure  by  the  accumulated  gummy  deposit. 
Not  producing  suppuration  or  caries,  but,  by  pressure, 
causing  absorption  of  the  bony  structure  without  in- 
flammation, without  suppuration,  without  caries.  In 
this  way,  and  in  this  way  alone,  can  cases  of  so-called 
dry  caries,  initiated  without  inflammation,  progressing 
to  well-recognized  loss  of  bone  structure,  without  sup- 
puration, or  caries,  be  satisfactorily  accounted  for. 

SYPHILITIC   DACTYLITIS. 

G.  B.  W.,  printer,  45  years  old ;  tall,  delicate ;  has 
never  been  strong ;  supposed  himself  of  scrofulous 
diathesis,  as  his  mother  was  affected  with  a  "salt 
rheum."  In  i860  had  an  injury  of  the  left  leg  which 
developed  an  indolent  ulcer.  From  long-standing  at  his 
business  this  continued  open,  during  six  years,  and  was 
known,  and  treated  from  time  to  time,  as  the  "printer's 
sore  leg."  Became  an  editor,  and  thus,  relieved  from 
necessity  of  standing,  the  ulcer  healed.  After  this, 
occasionally  took  sarsaparilla,  iodide  of  potass.,  etc.,  for 
his  supposed  scrofulous  diathesis.  Remembers  to  have 
had  dull  pains  in  his  muscles,  and  also  in  bones:  had 
also  slight  pain  in  fingers  of  right  hand.  These  pains 
were  reheved  by  application  of  tr.  of  iodine.  Never 
had  any  evidence  of  an  initial  lesion  of  syphilis,  or  any 

natural  tissues,  and  cause  the  atrophy  of  more  or  less  of  the  substance  of 
the  latter,  even  while  there  is  apparently  a  hypertrophy,  as  evidenced 
by  the  little  tumor  called  a  tubercle.  When,  however,  the  adventitious 
newly  formed  cells  go  into  atrophy,  and  are  absorbed  during  the  pro- 
gress of  the  eruptions,  then,  not  only  does  the  tubercular  prominence 
disappear,  but  the  scar  left  attests  the  atrophy  and  absorption  of  the  true 
elements  of  the  skin  tissue,  which  took  place  during  the  deposit  of  the 
morbid  material." — Van  Buren  and  Keyes  on  "  Genito-Urinary  Diseases 
with  Syphilis,"  p.  583.  D.  Appleton  &  Co.,  New  York,  1874. 


l86  PRACTICAL  CLINICAL  LESSONS  ON 

sore  on  any  part  of  his  body  which  was  suspected  to  be 
such.  Pain  in  his  fingers  first  noticed  about  two  years 
ago.  Injured  his  fingers  sUghtly,  and  sweUing  began. 
This  was  treated  by  local  application  of  tr.  iodine,  but  it 
continued,  and  after  a  few  months  the  finger  became 
distorted  in  shape,  and  appeared  shorter  than  before. 
Middle  finger  of  opposite  hand  then  began  to  swell, 
like  the  first,  without  special  pain.  Physicians  Avho  ex- 
amined him,  attributed  his  difficulties  to  scrofula,  and 
for  several  months  he  took  hydriodic  acid,  cod-liver  oil, 
etc.  General  health  much  improved  but  local  trouble 
remained.  Careful  questioning  failed  to  elicit  evidence 
of  any  lesion  of  acute  syphilis.  A  deeply  copper-colored 
scar  was  found  on  the  site  of  the  chronic  ulcer  of  the 
leg,  previously  described.  The  middle  finger  of  either 
hand  was  swollen  at  the  second  joint.  That  of  the 
right  hand  was  slightly  bent  towards  the  forefinger,  and 
shorter  than  the  left  by  fully  half  an  inch  ;  slight  crepita- 
tion and  slight  tenderness  on  pressure;  increased  mobil- 
ity at  the  joint,  which  was  evidently  due  to  loss  of  bony 
tissue,  chiefly  in  the  distal  end  of  the  second  phalanx. 
The  second  joint  of  the  middle  finger  of  the  left  hand 
was  swollen,  slightly  sensitive  on  pressure;  this  trouble 
was  comparatively  recent,  having  occurred  within 
three  or  four  months.  The  characteristics  of  the  bony 
lesions  in  this  case  were  distinctly  those  of  dactylitis 
syphilitica,  and  yet  there  was  no  syphihtic  history  to  be 
obtained.  The  patient  then  remarked  that  he  had  a 
small  sore  on  his  back,  which  had  been  bothering  him 
slightly,  for  several  weeks.  Examination  showed  a 
sharply  cut  ulceration,  about  the  size  of  a  silver  half- 
dollar,  extending  through  the  thickness  of  the  skin,  per- 
fectly characteristic  of  a  late  syphilitic  ulcer,  due  to 
breaking  down  of  a  gummy  infiltration  or  accumu- 
lation. This  settled  the  diagnosis  beyond  a  question, 
and  the  patient  was  at  once  put  upon  an  anti-syphilitic 
treatment.  Iodide  of  potassium  in  even  three  or  four 
grain  doses  caused  gastric  irritability.  Iodoform,  which 
had  been  previously  well  borne,  was  resumed,  i  gr. 
(Warner's  pills)  thrice  daily,  and  J  gr.  of  the  protoiodide 
of  mercury;  also  mercurial  fumigations,  twice  week- 


SYPHILIS   AND   THE    GENITO-URINARY   DISEASES.    187 

ly.  This  was  continued  for  a  month,  with  some  appre- 
ciable benefit,  and  especially  to  the  sore  on  the  back. 
This,  treated  locally  with  iodoform,  had  entirely 
healed,  when  the  patient  began  to  complain  of  tender- 
ness of  his  gums.  Fumigations  were  omitted.  The 
patient  was  not  seen  again  until  March  3,  1883.  The 
pills  of  iodoform  and  proto-iodide  of  mercury  had  then 
been  taken,  twice  daily  (a  third  pill  always  causing 
digestive  discomfort),  for  fully  fifteen  months.  The 
second  joint  of  the  right  middle  finger,  previously 
affected,  was  now  apparently  normal  in  every  respect. 
That  of  the  right,  was  free  from  tenderness,  or  any  sign 
of  inflammatory  trouble,  and  was  also  reduced  in  size. 
The  mobility  was  much  increased.  The  first  and 
second  phalanges  appeared  atrophied  and  shortened  as 
in  the  accompanying  sketch.  There  was  no  longer  any 
evidence  of  present  diseased  action,  and  discontinuance 
of  specific  treatment  was  advised. 

Remarks. — Nothwithstanding  the  failure  to  obtain  any 
proof  of  acquirement  of  syphilis  in  this  case,  the  pecu- 
liar history,  appearance,  and  nature  of  the  deformity  of 
the  fingers,  made  its  syphilitic  origin  almost  a  certainty. 
The  presence  of  a  characteristic  late  syphilitic  ulcer 
set  the  question,  if  one  could  have  been  raised,  per- 
fectly at  rest.  Ordinarily,  a  full  course  of  treatment 
suitable  for  late  syphilitic  lesions,  viz.,  small  doses  of 
mercury  and  gradually  increasing  doses  of  iodide  of 
potassium  would  have  been  employed,  but  the  idiosyn- 
cracy  of  the  patient  prevented.  And  yet  under  the 
mild  continuous  use  of  iodoform  and  proto-iodide  of 
mercury  the  case  went  on  without  discomfort,  to  com- 
plete recovery  in  the  right,  and  the  same  (leaving  only 
deformity  from  previous  bony  loss)  in  the  left. 

The  nature  of  the  lesion  in  this  case,  is  almost,  if  not 
precisely,  identical  with  that  of  the  former  one,  in  which 
the  so-called  dry  caries — loss  of  bone  without  necrosis — 
was  present.  It  has  been  shown  to  be  due  to  accumula- 
tions of  germinal  material  (gumm}^  deposits)  in  and 
around  the  joints.  Absorption  of  bony  material  causes 
the  final  derormit}^  and  this  is  brought  about  by  press- 
ure from  purely  mechanical  conditions.    A  full  and  most 


l88  PRACTICAL  CLINICAL  LESSONS   ON 

admirable  account  of  dactylitis  syphilitica  may  be 
found  in  Bumstead  &  Taylor  on  Venereal  Diseases, 
(Phila.,  1879,)  P-  671?  ^^  ^^Q'  ^"^  P-  ^75  they  remark: 
''These  bony  swellings  may  remain  in  an  indolent  con- 
dition for  along  time,  and  finally  the  gummy  deposit 
may  be  absorbed,  or  it  may  soften  and  be  discharged  , 
through  a  sinus.  .  .  .  The  cib  sorption  of  the  bone  is  unac- 
companied by  ulceration  of  the  soft  parts  ^  (p.  576). 

In  the  excellent  work  on  Genito-Urinary  Diseases 
with  Syphilis,  by  Van  Buren  &  Keyes,  (N.  Y.,  1874,)  page 
625,  they  say  of  such  cases:  ''Appearances  similar  to 
those  found  in  dry  caries  have  been  encountered  in  the 
affected  phalanges  after  death.  The  gummy  deposit, 
after  producing  great  swelling  of  bone  by  its  infiltra- 
tion, undergoes  absorption  zvithout  ulceration,  as  in  dry 
caries,  and  results  in  loss  of  substance  of  the  bone, 
which  is  not  replaced  by  new  tissue.  If  very  rapidly 
formed,  the  gummy  deposit  may  undoubtedly  break 
down  and  be  eliminated  externally." 

It  is  immaterial  in  regard  to  treatment,  whether  the 
so-called  gummy  deposit  is  in  the  bone  structure,  in  the 
fibrous  or  cartilagenous  structures,  or  in  the  adjacent 
soft  parts :  wherever  it  is  imprisoned,  so  as  to  produce 
mechanical  pressure,  the  parts  must  yield  sooner  or 
later,  either  slowly,  through  absorption,  or  setting  up 
an  inflammatory  process,  more  or  less  acute,  cause 
death  of  tissue.  The  same  behavior  of  the  so-called 
gummy  material  will  be  recognized  in  every  kind  of 
late  or  tertiary  lesion  (s3^phihtic  sequelse),  viz.,  absorp- 
tion of  unyielding  surrounding  structures  from  mech- 
anical pressure,  or  inflammation  and  suppuration  necro- 
sis through  direct  mechanical  injury,  or  indirectly 
through  destruction  or  impairment  of  vessels  of  nutri- 
tion. 


SYPHILIS   AND   THE  GENITO-URINARY  DISEASES.    1 89 


LESSON   XX. 

SYPHILITIC  SEQUELS   INVOLVING  NASAL  BONES,  VOMER 
AND  VAULT   OF  THE   HARD   PALATE. 

Clinical  case  in  illustration.  Treatment  by  internal  remedies.  Slow 
progress  through  this  agency.  Final  cure  without  deformity.  Second 
case  treated  by  mechanical  removal  of  necrosed  bone.  Operated  on 
through  nasal  orifices  by  means  of  the  dental  engine.  Prompt  re- 
covery. Syphilitic  necrosis  a  local  disease.  Early  removal  of  dead 
bone  advisable.  Recovery  usually  as  prompt  as  when  the  disease  re- 
sults from  other  causes  than  syphilis. 

B.  W.;  37.  Syphilitic  history :  active  stage  three  years 
previous ;  irregularly  treated  for  about  a  year,  during 
which  he  had  a  sparse  papular  eruption  lasting  a  couple 
of  months,  also  ulcers  in  the  mouth  and  throat  at  the 
same  time.  Since  then,  had  no  evidence  of  syphilitic 
trouble,  until  about  three  months  previous,  when  he  be- 
gan to  have  slight  pain  in  his  nose  with  some  nasal 
catarrh.  This  continued  to  annoy  him,  the  discharge 
increasing,  and  finally  tinged  with  blood,  and  at  times 
quite  foetid ;  tenderness  over  the  nasal  bones  also  in- 
creased, and  a  redness  appeared,  with  increased  soreness. 
Had  been  under  care  of  physician,  who  gave  him 
internally  some  iodide  of  potassium,  and  a  wash  to  use. 
This  dissipated  the  odor,  but  the  soreness  increasing 
he  concluded  to  seek  other  aid.  Examination  showed 
the  nostrils  filled  with  hard  black  scabs ;  odor  foetid. 
Probe  introduced  strikes  loose  bone;  a  flat  ragged 
piece  about  the  size  of  a  half-dime  removed  ;  quite  ex- 
tensive surface  of  dead  bone  recognized,  but  no  more 
could  be  removed.  Patient  put  upon  mist,  biniodid.,  i 
teaspoonful  thrice  daily.  Besides  this,  iodid.  of  potass., 
increasing  one  grain  at  each  dose  up  to  sixty,  largely 
diluted  with  milk ;  permanganate  of  potassium,  two 
grains  to  water  an  ounce,  to  be  used  through  a  syringe  in 
cleansing  and  deodorizing  the  parts.  Subsequently,  sev- 
eral pieces  of  turbinated  bone  came  away  and  also  several 
pieces  of  the  nasal  bones.  As  soon  as  any  portion  was 
found  loose  it  was  carefully  eliminated  ;  medicines  faith- 


190  PRACTICAL  CLINICAL  LESSONS  ON 

fully  used  ;  potass,  iodid.  up  to  3  i.  three  times  a  day, 
but  it  was  nearly  three  months  before  the  necrosed  bone 
ceased  to  separate,  and  the  discharge  to  lose  its  charac- 
teristic foetor,  and  finally  to  cease.  Fortunately,  the 
destruction  was  not  sufficient  to  produce  any  external 
deformity,  and  the  case  was  claimed  as  showing  pecu- 
liarly satisfactory  results  of  treatment. 

Case  II.  VV.  G.  H.;  aged  17.  History  of  active 
syphilis,  under  care  of  Dr.  Leving,  of  London.  A  lit- 
tle over  two  years,  after  began  to  suffer  with  foetid 
nasal  catarrh.  Was  said  to  have  been  treated  by  Mr. 
Walter  Coulson,  of  London,  with  iodide  of  potass.,  etc.; 
Trouble  continued  increasing,  when  he  presented  to  me 
early  in  Jan.,  1880.  Necrosis  extensive  and  was  evidently 
progressing ;  discharge  profuse ;  odor  foetid.  Probe 
touched  dead  bone  at  several  points,  and  some  small 
pieces  of  the  vomer  were  removed.  Tissues  cover- 
ing arch  of  hard  palate,  red  and  tender.  Patient 
put  upon  full  course  of  biniodid.  with  increasing  doses 
of  iodid.  potass.  In  the  course  of  a  few  days  the  in- 
flammation of  tissues  covering  hard  palate  increasing, 
a  perforation  ensued.  This  affected  patient's  voice  un- 
pleasantly, and  as  he  was  a  public  singer,  he  was 
greatly  disturbed,  and  begged  for  some  more  effi- 
cient mode  of  rehef.  Instead  of  encouraging  him  to 
wait,  under  an  efficient  specific  treatment,  until  the  slow 
separation  of  the  necrosed  bone  was  effected,  I  sent 
him  to  Dr.  J.  H.  Goodwillie,  whose  demonstrations  in 
removal  of  necrosed  bone  by  aid  of  the  dental  engine  I 
had  witnessed  on  several  occasions,  and  who  subsequent- 
ly published  an  account  of  the  case  at  my  request,  and 
has  sent  me  a  copy  for  insertion  in  this  place.  Of  the 
condition  of  the  patient,  Dr.  G.  says : 

"  He  now  has  necrosis  of  the  vomer  and  vault  of  the 
palate,  with  a  small  hole  in  the  latter.  Foetid  discharge 
from  the  nose,  occasionally  stained  with  blood  from  ex- 
cessive granulations.  Administered  iodide  of  potassium 
and  cod-hver  oil.  Local  treatment  consisted  in  blowing 
into  the  nasal  cavities  iodoform  and  camphor  triturated 
tp  an  impalpable  powder,  with  subnitrate  of  bisrnuth 


SYPHILIS   AND   THE   GENITO-URINARY  DISEASES.    I9I 

and  sulphate  of  potash,  to  reduce  the  superabundant 
granulations,  and  so  have  less  bleeding  during  the 
operation.  By  invitation  of  the  late  Professor  James 
R.  Wood,  M.D.,  to  deliver  a  clinical  lecture  on  extirpa- 
tion of  bones  of  the  mouth  and  nose,  I  operated  on  this 
patient  at  his  clinic  at  Bellevue  Hospital,  January  15, 
1880.  Administered  four  ounces  of  whiskey  before  the 
operation,  and  kept  him  under  the  influence  of  nitrous 
oxide  during  the  operation,  which  lasted  about  fifteen 
minutes.  No  external  incision  was  made,  and  the 
necrosed  vomer  lower  portion  of  the  ethmoid,  both  in- 
ferior turbinated  bones  and  vault  of  the  hard  palate, 
were  removed,  by  the  revolving  knives,  through  the 
nostrils. 

No  portion  of  the  soft  tissue  on  the  hard  palate  was 
removed.  On  the  completion  of  the  operation,  he  was 
directed  to  blow  his  nose,  to  free  his  nasal  cavity  of  the 
cut-up  necrosed  bones  and  blood,  and  then  he  was  posi- 
tively forbidden  to  again  blow  his  nose,  for  the  next 
twenty-four  hours.  After  that  time,  the  clotted  blood 
was  carefully  removed  by  the  dressing  nasal  forceps,  and 
the  nasal  cavity  completely  covered  by  blowing  in  the 
iodoform  and  camphor  powder. 

"  On  the  second  day  a  nasal  douche  was  given  before 
the  application  of  pov/der. 

*'  On  the  next  day  after  the  operation  he  was  able  to 
attend  to  his  daily  duties. 

"The  wax  model  illustrating  his  case  shows  the  open- 
ing in  the  palate  one-fourth  inch  in  length  before  the 
operation.  Atrophy  of  the  nose  before  the  operation, 
from  the  non-respiration  and  constant  blowing  of  the 
nose,  as  seen  in  the  right  ala,  and  the  development  of 
the  ala,  as  seen  in  the  left  side  of  the  nose,  after  the 
operation. 

"  The  other  model  shows  the  opening  in  the  palate 
closed  and  a  new  deposit  of  bone  over  the  palate. 

'*  He  is  in  perfect  health  at  the  present  time." 

In  syphilitic  caries  involving  the  vomer,  the  nasal 
and  turbinated  bones,  and  contiguous  bony  structures 
dif^cult  of  access  to  ordinary  surgical  proceedure,  the 
removal  of  diseased  bone  requires  especial  instruments 


192  PRACTICAL  CLINICAL  LESSONS   ON 

and  skill  not  within  the  reach  of  the  ordinary  surgeon. 
The  dental  engine  affords  access  to  such  necrotic  pro- 
cesses, and  until  the  surgeon  can  personally  avail  him- 
self of  the  facilities  it  affords,  for  removal  of  carious 
bones  in  such  situations,  it  is  my  opinion,  that  the 
best  course  will  be,  to  relegate  cases  of  this  nature, 
to  men  who,  like  Dr.  Goodwillie,  have  the  mechani- 
cal skill  and  experience  in  the  use  of  the  dental  en- 
gine requisite  to  perform  the  operations  necessary  for 
the  complete  removal  of  diseased  bone  in  these  locali- 
ties. Otherwise  we  must  usually  follow  the  old  plan  of 
waiting,  until  the  separation  occurs,  through  the  tedious 
process  of  exfoliation,  aided  by  such  internal  remedies 
as  have  heretofore  been  relied  upon  for  the  care  of 
these  cases.  This  involves  the  danger  of  deformity, 
and  delay  in  cure,  which  it  seems  to  me  few  surgeons, 
aware  of  what  especial  skill  in  the  management  of  the 
dental  engine  can  accomplish,  will  feel  inclined  to  ac- 
cept. My  own  experience  in  several  cases  of  syphilitic 
caries  of  the  bones  of  the  skull,  where  I  had  operated 
for  removal  of  the  diseased  bone,  and  found  rapid  recov- 
ery result,  has  convinced  me  that,  when  syphilitic 
necrosis  occurs,  it  is  a  purely  local  matter,  and  that  it 
is  good  practice,  in  all  such  accidents,  to  remove  the 
dead  bone  at  the  earliest  practicable  period,  and  that,  as 
a  rule,  to  which  there  are  few  exceptions,  such  removal 
will  result  in  as  prompt  recovery  as  when  the  necrosis 
has  occurred  from  other  causes  than  syphilis. 


SYPHILIS  AND   THE   GENITO-URINARY  DISEASES.    I93 


LESSON   XXL 

GUMMY   TUMOR   OF   BONE — PRODUCING  BRAIN   SYMP- 
TOMS, ETC. 

Clinical  case  in  illustration.  Such  lesions  of  rare  occurrence  before  the 
second  or  third  year  of  syphilis.  Insidious  in  access.  Sometimes  pro- 
ducing extensive  loss  of  bony  tissue.  First  signs  often  through  oc- 
currence of  vertigo,  epilepsy,  aphasia,  or  paralysis.  Same  symptoms 
may  occur  from  accidents  of  the  acute  stage  of  syphilis.  Cases  in  illus- 
tration. Possibility  of  confounding  the  brain  and  nerve  disturbances 
of  late  syphilis,  with  those  due  to  processes  of  the  active  stage  of  the 
disease.     Mauriac's  views  in  support  of  this  position.     Cornil's  views. 

Case  VIII.  L.  G.,  35  ;  policeman.  In  good  general 
health.  Had  a  history  of  irregularly  treated  syphihs, 
twelve  years  previous.  About  five  years  ago,  he  first 
noticed  a  swelling  on  the  top  of  his  head  ;  also  soon 
after,  another  on  the  left  side :  not  tender,  causing  no 
inconvenience  or  pain.  About  a  month  after,  he  re- 
ceived a  blow  on  tumor  No.  i,  after  which  he  had 
much  pain,  and  it  finally  suppurated  and  discharged 
pus  freely.  Examination  showed  an  ulcer,  about  an 
inch  in  diameter,  perforating  the  scalp  just  anterior  to 
the  vertex.  The  probe  touched  bony  material  at  once, 
and  a  loose  piece,  half  an  inch  square,  was  readily  ex- 
tracted. The  second  and  more  recent  swelling  was 
about  the  size  of  half  a  pullet's  Ggg,  very  hard  and  in- 
sensitive. The  man  was  at  once  put  upon  a  mixture  of 
biniodide  of  mercury  and  iodide  of  potassium,  the  latter 
in  increasing  doses. 

The  open  lesion,  which  was  at  first  quite  painful,  soon 
became  less  so,  and  the  iodide,  at  the  end  of  a  month, 
had  been  raised  to  seventy  grains  three  times  a  day,  in 
a  tumbler  of  milk,  and  was  well  borne.  Within  three 
months  (notwithstanding  several  intervals  of  two  or 
three  days  each,  when  he  was  prevented  from  taking 
his  medicine)  the  hard  tumor  had  entirely  disappeared. 
His  only  complaint  was  of  occasional  vertigo.  This 
continued  after  the  healing  of  the  necrosed  lesion,  which 
occurred  a  month  or  two  later,  leaving  a  cicatricial  de- 


194  PRACTICAL  CLINICAL  LESSONS   ON 

pression  which  indicated  loss,  through  to  the  inner  table 
of  the  skull.  The  vertigo,  which  appeared  to  be  symp- 
tomatic of  a  bony  growth  on  the  inner  surface  of  the 
cranium,  after  some  four  months  more  of  treatment 
finally  disappeared.  He  was,  however,  kept  on  the  sim- 
ple mist,  biniodid.,  a  drachm  thrice  daily  for  the  follow- 
ing year,  and  he  has  had  immunity  from  trouble  for  the 
past  three  years. 

Remarks. — Tumors  of  the  cranium  rarely  occur  be- 
fore the  second  or  third  year  of  syphihs,  and  more 
often,  not  before  the  twentieth  or  later.  Their  access 
is  very  insidious,  and  as  they  are  usually  without  pain, 
often  come  to  considerable  size  before  discovery.  If 
the  patient  is  temperate,  and  in  good  general  health, 
they  may  remain  stationary,  at  any  point,  without  appar- 
ent change,  until  some  irregularity  in  living  or  depres- 
sion of  the  vital  powers,  disease,  or  injury  as  from  a 
blow,  when  they  inflame  and  break  down,  leaving  a 
bony  ulcer  involving  the  thickness  of  the  external  table 
and  the  diploe.  Penetration  of  the  internal  table  is  rare. 
The  extent  to  which  the  skull  may  be  damaged  in  this 
way  is  scarcely  conceivable.  The  same  mode  of  impli- 
cation may  extend  even  beyond  its  parictes  to  the 
bones  of  the  face.  The  first  announcement  of  trouble, 
in  cases  of  cranial  syphilis,  may  be  through  the  occur- 
rence of  some  nervous  trouble  from  pressure  on  the 
brain  ;  vertigo,as  in  the  case  just  cited  ;  epilepsy,  aphasia, 
or  muscular  paralysis.  The  reasonable  suspicion  of 
antecedent  syphilis,  should  be  the  signal  for  prompt  and 
efficient  treatment,  addressed  to  the  removal  of  syphilitic 
sequel2e.  Brciii  and  nerve  disturbance  occurring  during 
active  stage  of  syphilis^  during  the  early  months  of  syph- 
ilis, i.e.,  in  the  acute  or  secondary  stage,  localized  para- 
lysis or  acute  brain  disturbance  may  occur — not  due  to 
the  accumulation  of  the  so-called  gummy  material,whicli 
does  not  exist  during  the  active  stage,  but  from  the  pres- 
sure caused  through  the  formation  of  an  accidental  pap- 
ule, or  its  equivalent,  within  the  skull,  or  in  the  track  or 
sheath  of  a  nerve.  Quite  recently  1  have  seen  a  facial  para- 
lysis extending  to  the  hand  of  that  side,  in  the  papular 
stage  of  syphilis,  passing  off    under  treatment,  simul- 


SYPHILIS  AND   THE   GENITO-URINARY  DISEASES.     I95 

taneously  with  the  other  lesions  of  that  stage.  Within 
the  last  three  months  a  young  gentleman  under  my  care 
in  the  fifth  month  of  syphilis,with  papules,  though  sparse, 
yet  distinct  and  characteristic,  was  suddenly  attacked 
with  acute  mania.  Two  distinguished  alienists  of  this 
city  who  were  called  in,  pronounced  the  case  one  of 
commencing  paresis,  and  sent  the  young  man  to  Bloom- 
ingdale  Asylum.  In  the  course  of  a  few  weeks  he  was 
sufficiently  recovered  to  be  able  to  signify  to  his  medi- 
cal attendant  at  the  asylum,  that  he  was  under  treatment 
for  syphilis  when  attacked  with  his  mania,  and  showed 
the  stains  left  by  the  papules.  The  result  was  a  re- 
sumption of  treatment  for  syphilis  and  complete  recov- 
ery, within  a  very  short  time,  when  he  voluntarily  re- 
turned to  my  care. 

The  possible  error  of  mistaking  conditions,  like  the 
foregoing,  for  late  accidents  of  syphiHs,will  be  apparent.* 

Syphilitic  ostitis  and  periostitis,  osteophytes,  exostosis, 
epiphysial  and  parenchymatous,  enostoses  eburnation  of 
bone,  etc.,  of  the  active  period  oi  syphilis  may  be,  I  think, 
legitimately  claimed  to  result  from  one  and  the  same 
cause,  viz.,  the  cell  aggregation  and  proHferation,  in 
loco,  which  when  occurring  in  the  integument  constitutes 
the  papule. 

This  view  would  rationally  explain  the  position  of 
M.  Mauriac,  recently  quoted  in  the  American  edition  of 
Cornil  on  Syphilis,  and  which  thus  considered,  is  so 
entirely  in  harmony  with  my  own  position,  that  1  shall 
yield  to  the  temptation  to  quote  some  of  M.  Mauriac's 
statements  bearing  on  this  point.     He  says  :  f 

(i)  ''  Pericranial  periostitis  is  often  among  the  early 
manifestations  of  syphilis  .  .  .  even  before  the  secon- 
dary lesions. 

{a)  ''  It  is  seated  exclusively  in  the  periosteum  of  the 

*  An  accidental  papule  sometimes  may  be  seen  developing  in  the  an- 
terior chamber  of  the  eye  during  the  active  stage  of  syphilis,  which  has 
received  the  title  of  gummy  tumor  of  the  iris.  This  apparent  misnomer  is 
calculated  to  create  the  impression  that  gummy  tumors  do  sometimes 
occur  during  the  early  months  of  syphilis,  I  think,  which  can  be  satis- 
factorily proven  to  be  an  error, 

f  Cornil  on  Syphilis,  Am,  ed,,  1882,  page  264. 


I96  PRACTICAL   CLINICAL   LESSONS   ON 

cranium,  and  if  hypersemia  or  inflammatory  lesion  of 
the  osseous  tissue  exists  it  is  secondary  and  remains 
subordinate  to  the  periostitis. 

{b)  "  Pericranial  periostitis  is  the  result  of  a  true  in- 
flammatory process — an  irritation  or  active  process,  as 
indicated  by  its  acute  sj'mptoms  and  active  course. 

(The  same  ma}^  be  said  of  the  initial  lesion  of  syphilis, 
or  the  papular  eruption,  both  of  which  have  been  shown 
to  produce  irritation,  through  mechanical  obstruction 
to  the  processes  of  nutrition  rather  than  from  the  inflam- 
matory nature  of  the  lesions.)     He  further  says  : 

(c)  ''  This  variet}''  of  cranial  tumors,  when  a  result  of 
acquired  syphilis  in  the  adult,  /las  a  tendency  to  resolu- 
tion, either  spontaneously  or  by  appropriate  treatment. 
The  swelling  readily  disappears  withotct  leaving  any 
trace. 

(Italics  my  own,  to  indicate  the  exact  correspondence 
of  these  tumors  in  their  behavior  with  that  of  the  pap- 
ular eruption.) 

(/)  *'  The  tumors  may  be  discrete  or  confluent,  and 
usually  are  located  on  the  anterior  half  of  the  cranium. 
Their  duration  varies  from  four  to  six  weeks  when  not 
submitted  to  treatment.  Under  proper  medication  they  dis- 
appear sooner. 

(2)  "■  Periostitis  of  the  ribs,  costal  cartilages,  and  ster- 
num may  occur  at  the  beginning  of  syphilis. 

(3)  ''  Periostoses  and  exostoses  ma}'  develop  at  other 
parts  of  the  osseous  sj'stem  during  the  early  period  of 
constitutional  S3^philis. 

{a)  "  The  period  of  incubation  of  these  osseous  lesions, 
dating  from  the  appearance  of  the  chancre,  varies  from 
thirty  to  one  hundred  and  twenty  days. 

{b)  ''Thej^  may  appear  several  days  before  eruption 
of  the  secondary  cutaneous  or  mucous  lesions.  They 
occur  spontaneously  without  the  intervention  of  any 
exerting  cause. 

{c)  "■  They  seem  to  result  from  a  form  of  syphilitic  in- 
fection, in  which  the  virus  is  unusually  active,  as  com- 
pared with  the  resistant  powers  of  the  organism  con- 
taminated. 

(5 — ^)  "  They  may  recover  spontaneously,  but  they 


SYPHILIS  AND  THE  GENITO-URINARY  DISEASES.   I97 

disappear  very  much  more  rapidly  under  mercury  and 
iodine,  with  local  anti-phlogistic  treatment. 

{b)  "  They  complicate  the  prognosis  of  syphilis,  al- 
though they  are  often  associated  only  with  mild  lesions 
in  other  organs  and  do  not  necessarily  indicate  a  mahg- 
nant  local  process  or  serious  general  constitutional 
tendency." 

It  appears  to  me  to  require  a  very  moderate  degree 
of  perspicacity,  to  discover  a  remarkable  similarity,  in 
time,  mode,  and  degree  of  development,  in  behavior 
after  development,  with  and  without  treatment,  and  in 
relation  to  the  prognosis  of  a  given  case,  with  that  of 
the  papular  eruption.  Considering,  then,  the  power  of 
penetrating  through  any  and  every  tissue,  occasionally 
manifested  by  the  amoeboid  cell,  or  syphilitic  disease 
germ,  the  wonder  only  appears  to  be  that  such  acci- 
dents as  the  local  prohferation  and  accumulation  of 
such  cells,  in  various  localities,  outside  their  usual  chan- 
nels, are  not  more  frequently  observed.  The  proba- 
bilities appear  to  me  that  such  erratic  accumulations 
do  very  often  occur,  in  the  way  just  mentioned,  but, 
that,  as  the}^  are  most  likely  to  be  located  in  the  softer 
tissues,  the  mechanical  disturbance  is  not  sufficient  to 
attract  attention  ;  but  when  occurring  in  the  bony  struc- 
tures, or  between  these  and  the  periosteum,  very  natur- 
ally periostitis  of  the  mild  and  transient  character,  de- 
scribed by  Mauriac,  would  be  likely  to  take  place.  It 
is  also  a  significant  fact  that  such  proliferations  are 
favored  by  a  sluggish  circulation,  such  as  may  be  in- 
ferred, in  cases  as  Mauriac  says  (3)  "in  which  the  virus 
is  uimsually  active  as  compared  with  the  resisting  power  of 
the  organism  coittaminatedy 

In  connection  with  the  statements  of  Mauriac  and 
with  the  views  just  expressed,  it  will  be  interesting  to 
recall  what  M.  Cornil  says  as  to  the  mode  of  origin  of 
syphilitic  osteo-periostitis.  *'  Sj^philitic  periostitis  does 
not  differ  materially  from  ordinary  osteo-periostitis, 
limited  to  the  superficial  layer  of  the  bone  and  the 
periosteum,  it  most  frequently  occurs  at  the  end  of  the 
secondary  or  in  the  tertiary  period,  attacking  the  tibia, 
clavicle,  sternum,  bones  of  the  head,  etc. 


198  PRACTICAL  CLINICAL  LESSOKS   ON 

"  Beneath  the  periosteum,  between  it  and  the  bone, 
there  collect  7iumeroiis  roiuid  cells ^  analogous  to  those  of  em- 
b7yonal  marrow.  At  the  same  time  the  deep  layers  of 
the  periosteum  are  inflamed  and  contain  cells  mterposed 
between  the  fasceculi  of  fibres.  The  neighboring  connec- 
tive tissue  of  the  periosteum,  generally  presents  a  slight 
inflammatory  oedema,  so  that  the  tumor,  situated  be- 
tween the  skin  and  bone,  is  due  both  to  the  swelhng  of 
the  periosteum  and  to  the  inflammatory  oedema  of-  the 
subcutaneous  connective  tissue.  The  surface  of  the 
bone  beneath  the  periosteum,  has  the  openings  of  the 
Haversian  canals  enlarged  and  filled  with  marrow, 
which  is  either  red  and  embryonal,  or  is  gray  and 
gelatinous,  consisting  of  the  round  cells  of  the  medulla. 
The  fat  has  disappeared  from  these  changed  canals. 
This  form  of  mild  periostitis  may  disappear  and  leave  no 
trace,  even  when  it  is  quite  deep,  and  in  a  flat  bone,  as 
the  sternum  ribs  or  cranium.  It  is  accompanied  with 
an  embryonal  condition  of  the  marrow  of  the  whole 
bone."  (Cornil  on  Syphilis,  Am.  Ed.,  Henry  C.  Lea's 
Son  &  Co.,  Phila.,  1882,  pages  247,  248. 


Syphilis  and  the  genito-Urinary  diseases,  igg 


LESSON  XXII. 

LATE   BRAIN   LESIONS   OF  SYPHILIS— GUMMOUS   INFIL- 
TRATION OF. 

Clinical  case  in  illustration.  Prompt  beneficial  effects  of  specific  treat- 
ment. Large  doses  of  iodide  of  potassium  evidently  beneficial.  Prompt 
retrogression  in  patient's  condition  through  their  discontinuance.  Re- 
newed improvement  through  resumption  of  remedies  in  mild  form, 
and  subsequent  deterioration.  Resumption  of  large  doses  of  iodide  of 
potassium  objected  to,  and  final  relapse  of  the  patient  resulting  in  con-^ 
firmed  dementia.  Remarks.  Mr.  Hutchinson's  views  of  the  diseases 
of  the  brain  due  to  syphilis.  Correspondence  of  the  same  wiih  condi- 
tions in  foregoing  case.  Suggestions  of  treatment  for  similar  cases. 
Iodide  of  potassium  in  large  doses  claimed  to  be  essential  in  treatment 
of  the  sequelae  of  syphilis.  This  confirmed  by  experience  of  accepted 
authorities. 

W.  S.  S.,  37  ;  civil  engineer.  History  of  a  mild  form 
of  syphilis  at  24;  indurated  initial  lesion  ;  sparse  pap- 
ular; syphilide ;  partial  alopecia;  mucous  patches  in 
throat.  Desultory  treatment  by  mercurials  for  three 
or  four  months.  No  appreciable  evidence  of  disease 
after  the  sixth  month. 

Eleven  years  after,  while  in  South  America,  engaged 
in  very  engrossing  mercantile  business,  while  in  robust 
general  health,  he  gradually  became  conscious  of  a  fail- 
ing and  uncertain  memory.  His  partners  had  observed 
this  previously.  He  became  also  unusually  emotional ; 
tears  coming  without  due  occasion.  He  would  drop 
asleep  over  his  ordinary  work,  omit  words  in  his  busi- 
ness letters,  recognizing  this  himself,  on  reperusal.  He 
continued  for  two  or  three  months  to  transact  business, 
but  was  no  longer  trusted  to  do  so  without  supervis- 
ion. His  physicians  pronounced  his  trouble  acute- 
softening  of  the  brain,  and  he  was  sent  home.  He 
came  under  my  care  in  March,  1878.  He  was  still  in 
excellent  health.  In  addition  to  the  foregoing  symp- 
toms, he  had  some  aphasia  and  slowness  of  utterance ; 
he  was  no  longer  able  to  correct  his  written  mistakes 
as  before,  but  was  able  to  give  a  connected  account  of 
his  trouble  and  also  of  his  previous  syphilis.     He  had 


200  PRACTICAL  CLINICAL  LESSONS  ON 

Up  to  this  time  been  treated,  chiefly,  by  use  of  the 
bromides  and  strychnia,  but  had  slowly,  but  steadily, 
deteriorated  mentally,  while  his  general  health  was  yet 
perfect.  He  was  an  excessive  smoker,  and  drank  alco- 
holic beverages  two  or  three  times  a  day. 

Mr.  J.  was  at  once  put  on  the  mist,  biniodid.  hydrarg. 
a  teaspoonful  thrice  daily,  with  the  addition  of  one 
drop  of  a  saturated  solution  of  the  iodide  of  potass, 
with  each  dose,  in  half  a  small  tumbler  of  milk  thrice 
daily.  Smoking  and  spirituous  liquors  wholly  inter- 
dicted— plain  wholesome  food,  regular  hours,  took  the 
place  of  ill-selected  food  and  late  hours.  The  solution 
of  the  iodide  was  increased  by  one  drop  for  each  dose 
of  the  mixture,  and  given  separately  from  it  in  a  half 
tumbler  of  milk,  and  this  continued  up  to  the  tenth  day, 
when  he  was  taking  30  drops  or  30  grains  of  the  iodide 
of  potass.,  besides  the  8  grains  in  his  biniodide  mixture 
in  which  he  got  also  -^-q  of  a  grain  of  the  biniodide  of 
mercury.  Already  there  appeared  some  signs  of  amend- 
ment. The  iodide  was  now  increased  more  slowly : 
only  one  drop  per  day  instead  of  one  at  each  dose,  as 
he  complained  of  a  little  sense  of  nausea  at  times  after 
taking  the  medicine.  The  milk  was  increased  so  that 
at  the  end  of  the  third  week  from  this  he  was  taking  $2 
grains  in  a  tumbler  of  milk,  besides  his  mixture,  con- 
taining 8  grains  more,  making  one  full  drachm  of  the 
iodide  of  potassium,  and  -^  oi  a.  grain  of  the  biniodid. 
of  mercury  three  times  daily,  and  bearing  it  perfectly ; 
smoking  but  one  cigar  daily  and  drinking  but  claret 
with  his  dinner.  He  had  now  improved  so  much  that 
his  friends  remarked  it  on  meeting  in  the  street.  He 
was  less  somnolent,  and  his  difficulty  of  utterance  was 
scarcely  noticeable,  as  he  was  naturally  slow  of  speech. 
This  treatment  was  continued  without  change  in  any 
particular  for  three  months,  with  gradual  improvement, 
when,  notwithstanding  several  lapses  in  his  abstinence 
— on  one  occasion  dissipating  for  several  days — he  had  so 
far  recovered  that  he  considered  himself,  and  his  friends 
considered  him,  quite  well.  His  medicines  were  given, 
however,  with  the  distinct  understanding  that  unless 
some  especial  contra-indication  occurred,  they  should  be 


SYPHILIS  AND   THE   GENITO-URINARY   DISEASES.     201 

continued  in  same  doses,  viz.,  i  drachm  of  potass,  iodide, 
and  yig-  hydrarg.  biniodid.  ttirice  daily  for  at  least  one  year. 
Continuing  apparently  well  for  the  next  few  months,  he 
went  to  London,  where  he  consulted  an  expert,  who, 
while  approving  the  previous  treatment,  thought  it  had 
been  continued  long  enough  and  directed  that  it  be  dis- 
continued. At  the  end  of  a  month  the  patient  went  to 
Paris,  and  after  a  short  period  of  dissipation  was  seized 
with  acute  mania  and  was  placed  in  a  Maison  de  Sante, 
where  he  soon  became  aphasic  and  somnolent,  and 
his  case  was  accepted  as  one  of  acute  idiopathic  cere- 
bral ramoUissement.  A  history  of  the  case  was  sent 
to  the  physicians  then  in  charge  of  the  case,  with 
suggestion  to  resume  the  former  specific  treatment. 
Unaer  mercurial  inunctions  and  small  doses  of  potass, 
iodid.  the  patient  once  more  improved,  and  hopes  of 
complete  recovery  were  held  out.  From  being  unable 
to  recognize  his  relations,  even  requiring  aid  in  all  the 
operations  of  his  excretory  functions,  and  even  sitting 
at  times  with  open  mouth  and  food  unmasticated  in  it, 
he  became  able  to  help  himself  in  all  ways,  to  write 
legible  and  coherent  sentences  and  dates,  to  recognize 
and  converse  intelligibly,  though  with  thick  and  at 
times  somewhat  difihcult  utterance.  At  this  time,  being 
in  Europe,  I  was  desired  to  see  him  in  consultation 
with  the  medical  officers  under  whose  care  he  was,  and 
found  him  in  the  condition  last  above  described.  The 
former  diagnosis  of  the  syphilitic  origin  of  the  trouble 
was  concurred  in  by  the  resident  physician,  but  great 
surprise  was  expressed  at  the  magnitude  of  the  doses 
of  iodid.  of  potass,  which  had  been  used.  When  their 
immediate  resumption  was  urged,  a  deprecating  shrug 
accompanied  the  consent  given,  and  it  seemed  scarcely 
probable,  although  the  recommendation  was  enforced 
by  cases  and  authorities,  that  the  patient  would  get  the 
full  measure  of  what  was,  evidently,  considered  heroic 
treatment.  Within  a  few  months  he  began  to  retro- 
grade; had  frequent  epileptiform  seizures,  and  now, 
after  a  year,  is  still  under  the  same  care,  in  a  state  of 
hopeless  dementia. 


202  I^RACTICAL  CLINICAL  LESSONS  ON 

Remarks. — Mr.  Hutchinson,  of  London,*  in  discuss- 
ing the  diseased  conditions  of  the  brain  due  to  syphilis, 
says,  "  If  we  say  that  we  recognize  three  forms  of 
cerebral  disease — one  in  which  the  symptoms  result  from 
arterial  occlusion,  one  from  irritation  of  gummata,  and 
one  from  periosteal  thickening — we  may  assume  that 
sudden  attacks  of  paralysis  denote  one,  that  the  second 
has  all  the  symptoms  common  to  cases  of  tumor,  and 
that  severe  pain  and  headache  go  with  the  last.  .  .  .  No 
doubt  in  some  cases  all  three  lesions  present  together, 
and  in  many  two  of  them."  The  probabilities  seemed 
to  me  in  favor  of  the  accumulation  of  germinal  material 
(gummy  deposits)  in  the  adventitia  of  arteries,  as 
described  by  Heubnerf  and  by  Edes,  :j:  sufficient  to 
produce  in  the  first  instance  sj^mptoms  of  pressure,  then 
of  irritation,  finally  obstructed  circulation  and  conse- 
quent softening.  The  two  causes,  viz.,  arterial  occulu- 
sion  and  irritation  and  pressure  from,  gummata,  combin- 
ing in  this  case.  The  prompt  benefit  from  specific 
treatment  in  the  first  instance  warrants  the  belief  that 
its  continuance  as  originally  contemplated  would  have 
not  only  prevented  the  relapse  but  in  all  probability 
have  resulted  in  permanent  cure.  In  any  event  the  fair 
and  full  trial  of  it  could  not  have  eventuated  more 
disastrously  than  its  omission.  Similar  accumulation 
(gummy  deposits)  occurring  in  the  spinal  cord  or  at 
any  point  throughout  the  nervous  system,  producing 
paralysis  in  various  localities  and  degrees,  even  in  some 
instances  perfectly  simulating  locomotor  ataxia,§  and 
general  paralysis  of  the  insane,  would  be  treated  with 
equal  benefit,  through  the  same  means  and  measures 
made  use  of  in  the  early  stages  of  the  foregoing  case. 
Inunctions  of  the  mild  mercurial  ointment,  a  drachm 
morning  and  evening,  instead  of,  or  even  in  cases  of 
urgency,  in  addition  to,  the  administration  of  mercurials 

*  London  Medical  Times  and  Gazette.  Feb.  7,  1877. 

f  Cornil  and  Ranvier,  Pathological  Histology.     Am.  Ed.,  p.  331. 

i  Physiological  Pathology  of  Syphilis.     Otis.     Putnam's  Sons,  1881. 

§  See  Professor  Erb's  paper  "  On  the  Role  of  Syphilis  as  a  Cause  of 
Locomotor  Ataxy,"  in  "Transactions  of  the  International  Medical  Con- 
gress," seventh  session.     London,  1881.     Vol.  ii.,  p.  32. 


SYPHILIS   AND   THE   GENItO-URlNARY   DISEASES.   203 

internally.  The  iodide  of  potassium  might  also  in 
obstinate  cases  be  carried  up  to  its  highest  point  of  toler- 
ance, or  until  the  urgent  symptoms  yielded.  As  high  as 
2  ounces  of  the  iodide  in  the  24  hours  have  been  admin- 
istered, with  final  relief  of  grave  destructive  late  lesions 
of  syphiHs.^ 

The  varieties  of  syphilitic  sequelse,  dependent  upon 
locality  and  tissues  involved,  it  will  readily  be  seen, 
may  be  interminable.  If  such  lesions  are,  as  is  claimed, 
dependent  upon  obstructed  lymphatic  channels  or 
spaces,  it  will  readily  be  seen  that  they  may  occur  at 
any  point  in  the  human  organism  to  which  nutritive 
material  is  carried.  The  attempt  to  classify  them  in 
regions,  organs,  and  tissues,  while  aiding  in  the  study 
of  special  symptoms  and  local  disturbances  due  to  their 
initiation,  development  and  progress,  unless  suitably 
guarded  by  explanation,  is  open  to  the  objection  that 
from  this  fact  they  are  liable  to  be  made  the  subjects  of 
consideration  as  so  many  varieties  of  disease  rather  than 
the  same  variety  simply  modified  in  appearance  and 
effects  through  the  influence  of  locality.  It  will  be  re- 
called as  a  significant  fact  that  no  matter  what  the 
locahty,  appearance,  or  symptoms  of  presumably  syph- 
ilitic origin,  one  and  the  same  line  of  treatment  is  indi- 
cated in  every  lesion  occurring  throughout  that  period 
of  syphilis  known  as  the  tertiary  and  quarternary  stages 
of  syphilis,  or  the  period  of  syphilitic  sequelae. 

*  Genito-Urinary   Diseases  with  Syphilis.      Van   Buren    and    Keyes. 
Appleton  &  Co.,  New  York,  1874,  p.  570. 


204  PRACTICAL  CLINICAL  LESSONS  ON 

LESSON  XXIII. 

SYPHILIS   OF   INFANTS   AND   HEREDITARY    SYPHILIS. 

Does  not  differ  essentially  from  syphilis  of  adults.  There  must  always 
be  a  syphilitic  disease-germ  to  initiate  the  disease.  Difference  in 
syphilis  of  the  embryo.  Syphilis  of  the  infant  and  syphilis  of  the 
adult  all  dependent  upon  the  same  influences,  modified  by  the  nature 
of  the  tissues  involved.  Treatment  of  all  must  be  based  on  same  prin- 
ciples. Reasons  for  this  view.  S5^philis  as  a  result  of  obscure  hered- 
itary influence  not  accepted.  Reasons  in  support  of  this  view.  Dis- 
ease of  embryo  or  infant  often  resulting  from  pre-existing  syphilitic 
disease  of  parents.  Not  necessarily  S3^philitic.  No  authenticated 
cases  of  syphilis  in  embryo,  or  infant  conceived  after  contagious  or 
active  stage  of  syphilis  in  parents  has  passed. 

If  the  position  taken  in  the  preceding  lessons  is  cor- 
rect— viz.,  that  sj^phiHs  is  the  result  of  undue  prolifera- 
tion of  germinal  cells,  brought  about  by  the  influence  of 
asyphilitic  cell  or  disease-germ,  which  has  been  brought 
in  immediate  contact  with  a  healthy  germinal  cell,  then 
all  syphihs  must  be  attributed  to  a  similar  cause.  There 
must  always  be  a  syphilitic  disease-germ  to  initiate  the 
disease.  The  different  modes  through  which  contact,  in- 
itiating the  disease  in  adults  or  children,  is  effected,  has 
already  been  explained.  Sj^philis  in  infants  cannot  dif- 
fer from  this,  except  so  far  as  the  disease  is  modified  by 
the  immature  tissues  in  which  the  disease  is  developed. 
The  treatment  of  sj'philis  of  infants  must  be  based  on 
the  same  prmciples  as  that  for  adults.  In  this  view, 
strictly  speaking,  there  can  be  no  such  thing  as  heredit- 
ary syphilis.  If,  as  has  been  shown  by  citation  of  numer- 
ous instances,  notably  b}^  results  of  the  recent  exten- 
sive observation  of  M.  Fournier  and  others — the  infec- 
tious property  of  syphilis  is  self -limited,  and  does  not 
continue  beyond  a  period  of  three  or  four  years,  all 
cases  of  transmitted  syphilis  beyond  such  period, 
whether  by  immediate  contact  or  through  alleged 
hereditar}^  influence,  becomes  impossible.  If  it  can  be 
shown  that  no  well-authenticated  case  of  transmission 


SYPHILIS  AND   THE   GENITO-URINARY   DISEASES.   20$ 

of  syphilis  has  occurred  beyond  a  period  of  three  or  four 
years,  as  has  been  claimed,  then  an  hereditary  influence 
extending  through  generations  cannot  be  accepted. 
The  necessities  for  the  production  of  syphilis  require  for 
its  initiation  a  disease-germ  of  sypJiilis.  The  development 
of  the  disease,  following  its  contact  with  healthy  cell 
elements,  is  well  understood — a  certain  definite  course 
in  its  progress  is  recognized  as  necessary  in  all  cases — 
a  stage  of  proliferation  with  contagious  non-destructive 
lesions — the  so-called  primary  and  secondary  periods — 
then  a  stage  of  accumulations  of  lymphatic  elements, 
non-contagious,  but  which  produce  destructive  lesions 
through  mechanical  interference  with  processes  of  nutri- 
tion. In  order,  therefore,  to  the  production  of  the  dis- 
ease in  the  adult,  in  the  infant,  or  in  the  embryo,  the  in- 
fecting cell  of  syphilis  must  first  be  brought  in  contact 
with  healthy  cell  material.  No  mysterious  hereditary 
influence  is  necessary,  or  can  be  admitted.  If  the  dis- 
ease-germ of  syphilis  by  direct  contact  with  external 
parts  or  through  its  amoeboid  power  traversing  tissue, 
reaches  healthy  cell  material,  whether  in  the  adult,  the 
infant,  or  the  embryo,  then  the  syphilitic  influence  is 
directly  transmitted,  and  its  development  must  be  gov- 
erned by  the  same  laws  that  characterize  its  progress  in 
the  known  behavior  of  the  disease  in  the  adult,  modified 
to  greater  or  less  extent  by  the  age  and  degree  of  sta- 
bility of  the  tissues  in  which  the  disease  is  developed. 
First,  the  localized  proliferation  and  accumulation  of 
cell  material  not  necessarily  destructive  ;  second,  accu- 
mulations of  cell  material,  which  induces  destructive 
action  through  interference  with  processes  of  nutrition. 
In  this  way  it  will  be  seen  that  syphilis  in  the  embryo, 
syphilis  in  the  infant,  syphilis  in  the  adult,  is  the  legiti- 
mate result  of  similar — in  point  of  fact  identical,  proc- 
esses— producing  results  which,  while  apparently  differ- 
ing in  many  respects,  may  yet  be  explained  in  complete 
harmony  with  the  known  behavior  of  S3^phiHtic  disease 
in  the  adult.  It  is  undoubtedly  the  fact  that  much  dis- 
ease in  foetal  and  infantile  life  results  from  pre-existing 
disease  in  the  generative  organs  of  the  parents,  who 
\iave  been  subjects  of  syphilis — but  that  any  syphilitic 


206  PRACTICAL  CLINICAL  LESSONS   ON 

disease,  proven  to  be  such  by  its  power  to  transmit 
syphilis,  has  been  communicated  to  healthy  persons,  by 
infants  conceived  after  the  active  or  contagious  stage  of 
syphilis  has  passed,  there  is  no  well-authenticated  evi- 
dence to  prove. 


SYPHILIS  AND   THE   GENITO-URINARY   DISEASES.    20/ 


LESSON   XXIV. 

CHANCROID:   ITS   NATURE   AND   TREATMENT. 

Definition.   Character.   Usual  origin.   Destructive.   Contagious.  Venereal. 
Description.     Secretion  always  inoculable.     Loses  power  in  each  suc- 

-  cessive  inoculation.  Under  favoring  circumstances  its  progress  self- 
limited.  Under  unfavorable  conditions  assumes  a  vicious  type. 
Phagedenic  form.  Serpiginous.  Extension  through  lymph  vessels  to 
glands,  producing  bubo.  Pus  from  chrancroidal  bubo  possesses  proper- 
ties of  original  sore.  Chancroid  varies  in  activity.  Activity  usually 
corresponds  to  that  from  which  it  is  derived.  Hence  every  grade,  from 
typical  chancroid  to  simple  excoriation  may  be  met.  History  of  chan- 
croid. At  one  time  confounded  with  syphilis  and  gonorrhoea  and  treated 
with  mercury.  Ricord  differentiates  between  gonorrhoea  and  chancroid, 
Bassereau  proves  the  distinctions  between  chancroid  and  syphilis. 
Clerc's  views.  All  pus  shown  to  possess  contagious  properties.  Low 
condition  favoring  production  of  sores  by  inoculation.  Dr.  Wiggles- 
worth's  experiments  proving  production  of  contagious  sores  from  sim- 
ple pustules.  Non-specific  nature  of  chancroid  thus  shown  to  be  prob- 
able. Causes  which  tend  to  intensify  its  activity.  Fournier's  experi- 
ence in  proof  of  this.  Conclusion  inevitable  that  chancroid  is  not  of 
specific  origin,  but  a  self-engendered  disease  resulting  from  stimulation 
and  vitiation  of  benign  natural  processes.  Chancroid  often  mistaken 
for  syphilis.  Necrosis  the  characteristic  of  chancroid.  Growth  the 
characteristic  of  syphilis  Manner  in  which  the  two  separate  diseases 
may  be  associated.  Difficulties  in  diagnosis.  Syphilis  and  chancroid 
never  in  any  relation  except  as  life  may  be  in  relation  to  death.  Syph- 
ilis always  the  type  of  rapid  growth  of  germinal  elements.  Chancroid 
always  characterized  by  death  of  tissue. 

Chancroid  is  an  acute,  contagious  ulcer,  recognized  as 
resulting  from  venereal  contact.  It  is  a  purely  local 
disease,  possessing  characteristics  which  entitle  it  to  be 
considered,  par  excellence^  the  highest  type  of  acute 
ulcerative  action.  In  the  great  majority  of  cases  it  is  the 
result  of  inoculation  of  the  purulent  secretion  of  an  al- 
ready existing  ulcer  of  a  similar  character.  Applied  to 
sound  integument  or  mucous  membrane,  it  is  capable, 
under  favoring  circumstances,  of  effecting  a  solution  of 
continuity  of  the  part,  and  of  communicating  to  it,  at 
once,  its  destructive  and  contagious  properties.  More 
commonly  and  readily,  it  is  established  upon  an  abrasioa 


208  PRACTICAL   CLINICAL   LESSONS   ON 

of  the  skin  or  mucous  membrane  produced  in  coitu.  On 
application  of  the  purulent  secretion  of  typical  chancroid 
to  an  abrasion,  either  on  the  person  already  affected  or  on 
one  previously  free  from  the  disease,  congestion,  inflam- 
mation, suppuration,  rapid  destruction  of  tissue  follow  in 
quick  succession.  The  ulcer,  thus  formed,  presents  all 
the  characteristics  of  rapid  destructive  action.  It  is 
sharply  cut,  with  ragged  edges  and  pultaceous  floor, 
and  secretes  pus  freely.  Chiefly  characterized  by  its 
contagious  property,  the  chancroid  is  seldom  single, 
several  distinct  lesions  usually  presenting  at  the  same 
time.  Occurring  under  circumstances  of  good  general 
health,  cleanliness,  and  temperate  living,  its  progress  is 
usually  self-limited  ;  gradually  increasing,  from  two  to 
five  weeks,  it  acquires  a  diameter  of  from  three  to  six 
lines;  the  loss  of  tissue  is  then  slowly  restored,  and  a 
scar  like  that  of  an  ordinary  burn  is  left.  From  first  to 
last,  its  secretion  is  inoculable,  and  the  sore  is  capable  of 
being  reproduced  upon  the  person  bearing  it.  When 
reproduced  by  artificial  inoculation,  it  loses  its  conta- 
gious power,  in  each  successive  inoculation,  until  the 
secretion  from  it  is  no  longer  inoculable.  It  will  thus  be 
seen,  that  the  tendency  of  the  disease,  under  favoring 
conditions,  is  always  towards  recovery.  When  acquired, 
under  unfavorable  conditions  however,  such  as  a  de- 
praved constitution,  irregular  life,  filth,  and  alcoholic 
excess,  the  chancroid  assumes  its  most  vicious  type. 
Characterized  now  by  a  high  grade  of  inflammatory 
action  and  an  increased  destructiveness,  it  not  unfre- 
quently  takes  on  a  pecuhar  action  which  is  termed /Z/^- 
gedenic,  through  which,  in  a  few  days,  or  even  hours, 
important  loss  of  tissue  ensues,  not  rarely  resulting  in 
irretrievable  mutilation,  and  possibly  in  loss  of  life.  In 
other  rarer  instances,  the  chancroid  takes  on  a  sluggish 
but  persistent  form,  known  as  the  serpiginous,  with  a 
gradual,  irregular  loss  of  tissue,  involving  the  integument 
only,  but  continuing  often  for  years  in  spite  of  every 
means  and  mode  of  treatment.  The  extension  of  the 
chancroid,  usually  by  continuous  tissue,  not  unfrequently 
takes  place  through  the  entrance  of  the  contagious  se- 
cretion into  a  lymphatic  vessel  (opened  by  chancroidal 


SYPHILIS   AND   THE    GENITO-URINARY   DISEASES.    209 

ulceration),  and  its  passage  along  that  vessel  to  the  ad- 
jacent lymphatic  gland.  This  accident  may  occur  at 
any  period  during  the  continuance  of  the  chancroid. 
The  gland,  in  this  manner  affected  (usually  in  the  groin, 
and  known  as  the  chancroidal  bubo),  becomes  tenderand 
swollen.  Evidences  that  the  peculiar  destructive  chan- 
croidal action  is  going  on,  within  the  substance  of  the 
gland,  become  daily  more  distinct,  until,  in  a  few  days, 
an  abscess  is  formed.  On  the  discharge  of  the  purulent 
contents  of  this  abscess,  they  are  found  to  possess  the 
peculiar  properties  of  pus  from  the  original  ulcer,  and 
the  open  bubonic  abscess  takes  on  the  appearances  and 
other  characteristics  of  the  t3^pical  chancroid. 

The  venereal  ulcer  or  chancroid,  in  its  early  stages,  is 
promptly  amenable  to  judicious  remedial  measures.  The 
application  of  any  caustic,  of  sufficient  power  to  destroy 
completely  all  the  tissue  which  has  been  implicated  in 
the  diseased  action,  suffices  to  change  the  contagious 
venereal  ulcer  to  a  simple  sore,  when  it  goes  on  to  recov- 
ery without  other  treatment  than  such  simple  sores  re- 
quire. The  conditions  which  determine  the  severer 
forms  of  the  chancroid,  are  recognized  as  already  stated. 
It  is  also  found  that  the  particular  lesion  which  may 
present,  partakes  in  great  degree  of  the  activity,  greater 
or  less,  which  has  characterized  the  lesion  from  which 
it  was  derived,  so  that  every  grade,  from  the  simple  ex- 
coriation to  the  sharply  defined  and  most  active  ulcer, 
may  be  met.  Hence,  all  do  not  require  the  prompt  and 
energetic  course  necessary  to  arrest  and  cure  the  typical 
chancroid.  In  the  milder  varieties,  the  judicious  applica- 
tion of  carbolic  acid,  iodoform,  sulphate  of  iron,  and 
other,  even  simpler  antiseptic,  sedative,  and  astringent 
agents,  may  suffice  to  bring  about  an  arrest  and  cure. 
In  the  lightest  forms,  it  is  often  difficult  to  distinguish 
from  non-venereal  pustules  which  result  from  acrid 
sebaceous  secretions,  or  from  connection  with  a  female 
suffering  from  an  acute  form  of  simple  leucorrhoea. 

In  regard  to  its  history,  the  chancroid  is  conceded  to 
be  of  ancient  origin,  even  to  antedate  the  advent  of 
syphilis.  It  has  various  synonyms — viz :  "  pseudo-syphi- 
lis," "  soft   chancre,"  "  non-infecting   chancre,"  ''  chan- 


210  PRACTICAL  CLINICAL  LESSONS   ON 

croid,"  etc.  By  the  latter  term,  chancroid^  it  is  almost 
universally  known  at  the  present  day.  It  was  distinctly 
recognized  and  described  by  the  ancients  as  a  disease 
known  from  the  earliest  times.  Notwithstanding  this, 
shortly  after  the  recognized  appearance  of  syphilis  in 
Europe  in  1492,  it  became  confounded  with  that  disease. 
Its  purely  local  character  was  obscured,  and  it  was  sub- 
jected to  constitutional  treatment  as  a  form  of  syphilis. 
Its  chief  characteristics,  however,  always  most  marked, 
were  never  quite  lost  sight  of.  Evincing  its  destructive 
property  at  once,  on  inoculation  of  its  secretion  upon 
healthy  tissue,  and  commonly  associated  with  inflam.- 
matory  enlargement  and  suppuration  of  contiguous 
lymphatic  glands,  it  was  thus  directly  opposed  to  the 
sluggish  course  of  the  syphilitic  local  affection  and  its 
non-suppurating  glandular  concomitants.  Yet  it  was  so 
often  found  associated  with  and  followed  by,  the  con- 
stitutional manifestations  of  S3^philis,  that  its  distinctive 
significance  was  doubted.  When,  after  a  time,  the  well- 
known  acute  venereal  ulcer  was  occasionally  observed 
exchange  its  soft  edge  and  base,  for  the  indurated 
tissue  known  to  characterize  the  early  syphilitic  lesion, 
the  fallacious  theory  oi  post  hoc  ergo  propter  hoc  prevailed, 
and  thus  the  confusion  of  the  two  distinct  diseases, 
became  complete.  From  this  time,  all  the  contagious 
venereal  diseases,  gonorrhoea,  chancroid,  and  syphilis, 
were  accepted  as  practically  identical,  requiring  the 
same  constitutional  treatment.  It  was  found,  however, 
after  the  habitual  mercurialization  of  persons  afflicted 
with  soft  sores  or  with  gonorrhoeas,  for  more  than  two 
hundred  years,  that  constitutional  syphilis  did  not  neces- 
sarily follow  the  occurence  of  the  soft  ulcer  nor  of  a 
gonorrhoea,  even  when  no  treatment  was  resorted  to, 
while  the  ulcer  with  indurated  base  and  edge  was  in- 
variably succeeded  by  the  general  manifestations  of 
syphilis.  John  Hunter  in  1786  was  the  first  to  recognize, 
publicly,  the  value  of  the  induration  characteristic  of  the 
venereal  sore  which  was  followed  by  constitutional 
syphilis,  thus  making  the  first  positive  step,  toward 
identifying  and  restoring  to  the  different  venereal  dis- 
orders, their  distinctive  individuahty.   Hunter,  however. 


SYPHILIS   AND    THE    GENITO-URINARY   DISEASES.    211 

misled  by  an  experiment  upon  his  own  person,  taught 
that  while  the  local  manifestations  of  the  venereal  dis- 
eases were  different,  their  source  was  identical,  and  that 
the  peculiar  form  and  nature  which  they  assumed  in  any 
given  case  was  dependent  upon  some  peculiar  condition 
or  idiosyncrasy  of  the  affected  individual.  In  1798,  Ben- 
jamin Bell  of  London  claimed  a  simple  origin  for  gon- 
orrhoea, and  in  1830,  M.  Ricord  of  Paris,  after  a  series 
of  observations  and  elaborate  experiments,  in  inoculating 
the  purulent  fluid  of  gonorrhoeas,  and  the  secretions  of 
the  soft  and  hard  venereal  lesions,  demonstrated  the 
purely  simple,  non-specific  nature  of  gonorrhoea,  thus 
completely  and  for  ever  eliminating  it  from  among  the 
manifestations  of  syphilis.  Ricord,  however,  notwith- 
standing his  numerous  and  carefully-observed  inocula- 
tions, and  while  distinctly  recognizing  the  local  and 
ultimate  differences  between  the  hard,  or  Hunterian, 
chancre  and  the  soft  sore  or  chancroid,  yet  accepted  and 
taught  Hunter's  view,  viz.,  that  the  difference  between 
them  was  not  one  of  origin,  but  of  personal  condition  or 
idiosyncrasy.  It  was  reserved  for  M.  Bassereau  of  Paris 
(a  pupil  of  M.  Ricord),  to  demonstrate  in  1852,  the  fact 
that,  in  the  disease  then  known  as  syphihs,  comprising 
the  soft  local  venereal  ulcer  and  the  indurated  infecting 
venereal  sore,  with  its  consequences,  two  separate  dis- 
eases existed.  Upon  the  confrontation  [i.e.,  personal 
comparison)  of  a  very  large  number  of  persons  affected 
by  venereal  disease,  with  those  from  whom  their  dis- 
ease had  been  acquired,  Bassereau  found  that  in  every 
person  presenting  a  venereal  ulcer,  accompanied  by 
well-pronounced  evidence  of  constitutional  syphilis,  the 
person  from  whom  the  disease  had  been  acquired  was 
also,  or  had  recently  been,  the  subject  of  ulcers  which 
were  followed  by  constitutional  syphilis,  and  that  in  no 
case  was  syphilis  ascertained  to  originate  from  a  person 
bearing  the  soft  venereal  ulcer  alone.  Similar  observa- 
tions, by  confrontation,  were  made  by  Messrs.  Dron, 
Clerc,  Diday,  Rollet,  and  Fournier  in  1856,  and  in  1857 
by  Messrs.  Fournier  and  Caby,  under  the  supervision  of 
M.  Ricord,  with  the  result  of  proving  that  in  all  cases 
of  chancroid,  the  type  of  ulcer  remained  unchanged  in 


212  PRACTICAL   CLINICAL   LESSONS   ON 

passing  from  one  individual  to  another.  Nevertheless, 
M.  Clerc,  while  accepting  and  confirming  the  obser- 
vations above  alluded  to,  claimed  to  have  produced  the 
typical  chancroid  by  inoculation  of  the  secretion  of  an 
infecting  (syphilitic)  chancre,  upon  a  person  previously 
the  subject  of  syphilis,  and  thus  to  have  demonstrated 
that  the  chancroid  was  the  product  of  the  inoculation 
of  the  syphilitic  virus,  upon  persons  then  or  previously 
affected  with  syphiHs.  Clerc  also  claimed,  that,  while, 
as  a  rule,  the  chancroid,  thus  originated,  usually  trans- 
mitted only  chancroid,  3'et  on  being  inoculated  upon  a 
healthy  person,  it  was  capable  of  reverting  to  its  original 
type,  and  hence  of  communicating  syphilis  ;  thus  assert- 
ing the  unity  of  origin  of  the  two  diseases.  Those  hold- 
ing this  view  were  known  as  unicists.  Rollet  and  others 
held,  on  the  contrarj^  that  not  only  were  chancroid  and 
chancre  (the  initial  lesion  of  syphilis)  separate  and  dis- 
tinct diseases,  but  that  they  owed  their  origin  to  separate 
and  distinct  poisons.  Thus  the  school  of  so-called  dual- 
ists was  initiated.  The  position  of  M.  Clerc  was  sup- 
ported by  the  observations  of  Henry  Lee  of  London, 
the  late  Prof.  Bock  of  Christiana,  Melchior  Robert,  and 
others,  who  succeeded  in  producing  the  typical  chan- 
croid upon  persons  syphilitic  and  non-spyhilitic  by  in- 
oculations of  pus  from  an  irritated  syphilitic  chancre. 
It  was  required  that  the  degree  of  irritation  in  all  cases 
should  be  sufficient  to  induce  a  iiQQ  purulent  secretion. 
Sores  produced  in  this  manner  were  inoculated,  in  suc- 
cessive generations,  upon  persons  quite  free  from  syphi- 
litic taint,  and  behaved  in  all  respects  like  the  ordinary 
venereal  chancroid.  It  was,  however,  found  that  when 
the  superinduced  irritation  subsided,  and  the  secretion 
was  no  longer  purulent,  it  was  no  longer  auto-inoculable. 
Hence  it  became  evident  that  the  property  of  inocula- 
bility  was  consequent  upon  a  peculiar  action  resulting 
from  the  persistent  irritation  of  an  already  diseased  sur- 
face. The  fact  that  the  chancroid  could  be  established 
upon  persons  entirely  free  from  syphilitic  taint,  and  not 
be  followed  by  syphrlis,  demonstrated  that  its  existence 
was  not  necessarily  dependent  upon  the  syphilitic  prin- 
ciple.    Experiments  were  then  made  by  Pick,  Bidencap^ 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.   213 

Koebner,  Bock  and  others,  to  ascertain  the  effect  of  in- 
oculations of  pus  from  simple  lesions  on  persons  free 
from  syphilitic  taint.  The  result  showed  that  affections 
in  non-syphilitic  persons  which  are  of  shght  virulence, 
the  secretions  of  which  are  not  inoculable,  can  be  made 
to  produce  an  inoculable  secretion  by  the  application  of 
an  irritant.  Kaposi  states  that,  in  his  experiments  the 
pus  taken  from  acne,  and  from  scabies  in  non-syphilitic 
individuals,  has  produced  pustules,  the  pus  from  w^hich 
was  inoculable  in  generations  on  the  bearer  as  well  as 
on  other  non-syphilitic  persons.  In  1866,  Dr.  Edward 
Wigglesworth,  Jr.,  of  Boston,"^  while  studying  under 
Prof.  Zeissl  of  Vienna,  and  being  entirely  free  from 
any  suspicion  of  venereal  taint,  but  in  somewhat  impaired 
general  health,  inoculated  his  own  arm  with  pus  taken 
from  a  simple  pustule  of  acne.  This  produced  a  similar 
pustule  at  each  of  the  three  points  of  inoculation.  Pus 
from  these  being  again  inoculated,  a  third  generation 
was  established.  Nine  distinct  sores,  the  result  of  the 
inoculation,  were  present  at  the  same  time,  and,  pursuing 
a  similar  course,  finally  healed,  leaving  as  many  distinct 
cicatrices,  indicative  of  loss  of  tissue  through  the  process 
of  ulceration.  This  experiment,  during  its  progress, 
was  under  the  personal  observation  of  Prof.  Zeissl,  and 
was  repeatedly  exhibited  to  his  class,  as  demonstrating 
the  contagious  and  destructive  properties  of  non-speci- 
fic pus,  under  certain  circumstances  unconnected  with 
syphilis,  or  with  any  venereal  influence.  Observations 
(personal)  have  shown  that  the  muco-purulent  secretion 
from  non-specific  nasal  catarrh  will  sometimes  produce 
excoriations  of  sound  cuticle.  That  contact  with  secre- 
tions from  non-specific  leucorrhoeas  will  sometimes 
promptly  cause  pustular  eruptions  {herpes)  of  the  pre- 
putial mucous  membrane  of  the  male  ;  and  these  more 
or  less  rapid  in  development  and  progress  according  to 
the  degree  of  activity  of  the  inoculating  secretion.  In 
some  instances  so  simple  that  they  are  scarcely  more 
than  sero-purulent  vesicles,  and  in  other  cases  observed 

*  Reported  by  Dr.  Bumstead  in  his  paper  "  On  the  Unity  and  Duality  ol 
Venereal  Sores,"  read  before  the  Centennial  Medical  Congress  of  Phila- 
delphia. 


2t4  PRACTICAL  CLINICAL  LESSONS   ON 

SO  vicious  that  in  appearance  they  do  not  differ  at  all 
from  the  typical  chancroid ;  the  secretion  being  also 
auto-inoculable,  as  proven  by  the  occasional  occurrence  of 
similar  lesions  upon  opposing  surfaces. 

Mr.  John  Morgan  of  Dublin,  in  his  work  on  venereal 
diseases  (1873),  cites  numerous  instances  in  which  he 
has  observed  the  tj^pical  chancroid  to  result  from  inocu- 
lation of  the  muco-purulent  secretions  of  leucorrhceas 
in  syphilitic  women,  upon  other  women,  also  subjects 
of  syphilis.  Vidal  cites  a  case,  where  pus,  taken  from  a 
pustule  of  simple  ecthyma,  in  a  patient  suffering  from 
t3'phoid  fever,  was  promptly  inoculable  on  the  patient, 
but  failed  when  inoculated  upon  a  healthy  person.  It  is 
therefore  shown  that  the  quality  of  pus  is  variable,  ac- 
cording to  the  circumstances  under  which  it  is  produced 
and  the  condition  of  the  person  upon  whom  it  may  be 
inoculated.  That  a  low  condition  of  the  general  system, 
from  any  cause,  predisposes  the  healthy  tissues  to  take 
on  ulcerative  action,  and  to  elevate  the  accompan3ang 
purulent  secretion,  to  a  point  of  contagiousness.  Les- 
ions, especially  of  mucous  membrane  of  the  human  geni- 
tal apparatus,  of  both  male  and  female,  are  common 
under  the  circumstances  peculiar  to  the  venereal  act. 
Inflammations  of  mucous  membrane,  in  the  same  local- 
it}^  are  frequent,  and  characterized  by  muco-purulent 
secretions,  often  profuse  and  acrid;  and  this,  too,  when 
the  subjects  of  them  are  in  good  general  health  and  living 
under  the  most  favorable  hygienic  conditions.  When, 
therefore,  it  comes  to  be  considered  that,  the  most  fre- 
quent habitat  of  the  chancroid,  is  in  localities  where 
venereal  excess  and  every  kind  of  debauchery  abound  : 
when  to  this  are  often  added  the  potent  element  of  syphi- 
lis and  scrofula,  hereditar}^  and  acquired,  filth,  and  irre- 
gular living  :  and  when  (as  has  been  shown  by  Fournier  ^ 
and  others)  chancroid  is  found  b}^  far  the  most  frequent 
in  proportion  to  syphilis  among  the  debased  and  disso- 
lute, the  conclusion  is  inevitable  that  chancroid  is,  and 

*  Fournier  noted  in  his  private  practice,  82  simple,  252  infecting. 
In  Hopital  du  Midi  of  341  chancres,  215  were  simple  ;  and  in  the  report 
of  service  in  the  same  hospital,  where  10,000  cases  of  venereal  sores 
were  treated,  8,045  were  said  to  have  been  simple  chancroids. 


SYPHILIS   AND   THE   GENITO-URINARY  DISEASES.   21 5 

of  necessity  must  be,  a  self-engendered  disease,  pos* 
sessing  no  specific  virus,  but  acquiring  its  power  for 
destruction  and  contagion,  througti  the  stimulation  and 
vitiation  of  benign  natural  processes. 

The  venereal  ulcer,  or  chancroid,  acquires  its  chief 
importance  from  its  liability  to  be  mistaken  for,  and 
treated  as,  the  initial  lesion  of  syphilis.  The  distinction 
between  the  two  lesions  at  the  outset  is  often  impossible. 
The  active  characteristic  of  the  chancroid  is  recognized 
as  a  necrosis — that  of  the  syphilitic  lesion  one  of  growth 
or  proliferation.  The  surface  of  a  sore,  then,  may  be 
the  field  of  chancroidal  action,  while  the  living  tissue 
beneath  may  be  at  the  same  time  a  centre  of  prolifera- 
tion of  syphilitic  disease-germs,  which  are  constantly 
gaining  access  to  the  general  circulation  through  the  con- 
tiguous lymphatic  vessels.  These  germs  may  be  origin- 
ally deposited  upon  a  simple  abrasion  or  one  already  the 
seat  of  chancroidal  action.  If  the  former,  the  imposition 
of  the  secretion  of  a  chancroid  upon  the  same  point,  if  the 
disease-germs  have  been  freshly  deposited,  might  cause 
their  destruction,  and  thus  leave  only  the  chancroidal 
element;  but  once  the  syphilitic  principle  has  extended 
below  the  surface  and  has  entered  a  l3^mphatic  vessel,  it 
has  gone  beyond  the  sphere  of  action  of  the  chancroid. 
The  only  method  of  determining  whether  a  given  chan- 
croid or  other  lesion,  occurring  after  a  suspicious  vener- 
eal contact,  is  or  is  not  to  be  followed  by  constitutional 
syphilis,  is  to  reserve  a  final  decision  for  full  forty  days 
subsequent  to  the  exposure.  This  course  should  be  pur- 
sued even  though  during  the  interval  the  suspected  les- 
ion, possessing  all  the  characteristics  of  the  typical  chan- 
croid, should  have  fully  healed.  If,  during  time  above 
specified,  no  hardening  of  the  tissues  composing  the  edge 
and  base  of  the  sore  has  taken  place,  nor,  if  healed,  of  the 
cicatrix,  nor  any  enlargement  of  the  adjacent  lymphatic 
glands,  can  be  discovered,  then,  and  not  until  then,  can 
the  patient  be  assured  that  he  has  had  an  uncomplicated 
chancroid,  and  that  no  syphilis  will  follow.  Those  milder 
forms  of  ulcerative  action  which  are  just  within  the  line 
of  distinction  between  the  simple  so-called  herpes  and 
the  chancroid,  are  the  most  frequent  to  exhibit  subse* 


2l6  PRACTICAL  CLINICAL   LESSONS   ON 

quent  evidences  of  syphilitic  infection.  By  reason  of 
their  inactivity,  they  are  less  likely  to  destroy  any  of  the 
germs  of  syphilis  which  may  come  in  contact  with  their 
surface. 

The  frequent  association  of  chancroid  with  syphilis 
will  never  lead  to  mistaken  identity,  if  it  is  constantly 
borne  in  mind,  that  syphilis  is  always,  in  all  its  manifesta- 
tions, a  process  of  growth,  of  proliferation.  The  most 
scientific  and  critical  examination  of  the  products  of 
syphilis,  from  the  initial  lesion  to  the  gummy  tumor ^  has 
never  been  able  to  detect  any  abnormal  material. 
Nothing  but  excessive  accumulations  of  tissue-building 
cells.  Chancroid,  on  the  other  hand,  from  its  inception 
to  its  cicatrization,  is  a  process  of  necrosis — literally, 
death  of  tissue.  So  that  syphilis  and  chancroid  are  al- 
ways, and  only,  in  relation  to  each  other,  as  life  to  death 
— each  the  highest  type  of  its  own  peculiar  action. 


SYPHILIS  AND  THE  GENITO-URINARY  DISEASES.   21/ 

LESSON  XXV. 

NATURE   OF  CHANCROID. 

Evidence  that  it  is  non-specific.  New  foci  of  contagion  essential  to  long 
continued  reproduction.  Difference  between  ctmtagious  ulcerations 
produced  by  various  irritants  and  by  contact  with  pre-existing  chan- 
croid only  one  of  degree  and  not  of  kind.  Changes  in  simple  purulent 
lesions  through  non-specific  causes  may  engraft  a  contagious  property 
upon  them  which  is  practically  identical  with  that  of  lineal  chancroid. 
Cases  in  illustration. 

Before  proceeding  farther  it  is  essential  that  the  nature 
of  chancroid  should  be  fully  appreciated. 

If  it  is  a  specific  disease,  that  is  to  say,  only  capable 
of  being  set  up  through  contact  with  the  secretion  of  a 
previously  existing  chancroid,  then  acquirennent  of  chan- 
croid is  proof  indisputable  of  criminal  venereal  contact, 
either  by  the  subject  of  it,  or  of  the  one  from  whom  it 
was  mediately  or  immediately  contracted.  It  will  at 
once  be  seen,  that  this  is  a  point  which  may  become  of 
great  importance  in  its  medico-legal  relations.  It  will 
then  be  worth  our  while  to  pass  in  review  some  of  the 
known  facts  bearing  upon  this  matter. 

First  let  us  determine  exactly  what  is  understood  by 
the  term  chancroid.  We  may  accept  the  usual  definition, 
namely,  that  sores  promptly  following  venereal  contact, 
(from  24  hours  to  8  or  10  days,)  possessing  the  destruc- 
tive and  contagious  property,  are  called  chancroid,  and 
are  claimed,  by  certain  authorities,  to  be  due,  in  every 
instance,  to  a  specific  virus. 

Fournier  says  this  in  the  most  emphatic  way,  thus  :  "  If 
all  the  patients  in  the  world  with  chancroid,  would 
avoid  contact  with  others,  until  their  malady  got  well, 
the  disease  would  cease  from  off  the  earth."  This  is 
quoted  in  a  recent  work  on  syphilis,  etc.,  by  Drs.  Van 
Buren  and  Keyes,  and  emphasized  by  a  positive  state- 
ment  that  chancroid  arises  only  from  chancroid."^ 

*  "  Genito-Urinary  Diseases  with  Syphilis."     New  York,  D.  Appleton 
&  Co.     Page  477. 


2l8  PRACTICAL  CLINICAL  LESSONS  ON 

It  is  known  and  accepted  that  chancroids  vary  in  ac- 
tivity, from  those  which  are  highly  contagious  and 
rapidly  destructive,  to  those  which  are  feebly  destructive 
and  are  inoculated  with  difBculty.  This  is  a  well-known 
clinical  fact,  and  has  been  repeatedly  proven  in  the 
experiments  with  artificial  inoculations  by  Bock  and 
others."^  "  A  certain  pus  is  employed  {'  chancroidal ') 
and  re-inoculated  until  it  will  no  longer  produce  a  pus- 
tule;  then  fresJier  pus  from  some  younger  chancroid,  until 
it  also  fails."  f 

If  this  decadence  takes  place  in  the  artificial  inocula- 
tion, it  is  not  reasonable  to  suppose  that  the  same  result 
would  be  reached  by  repeated  inoculations  through 
venereal  contact.  Hence  the  chancroid,  by  the  con- 
tinued re-inoculations  of  venereal  contact,  would  grow 
less  and  less  virulent,  as  communicated  from  person  to 
person,  until  it  finally  died  out. 

Unless  therefore  new  foci  of  contagion  were  created, 
or  nezv  virulence  added,  chancroid  would  long  ago  have 
ceased  from  off  the  earth.  We  must  then  take  one  of 
these  two  positions  in  regard  to  it ;  either  some  added 
virulence  must  be  accepted  as  arising  from  circumstances 
connected  with  the  venereal  contact  (since  it  has  been 
conclusively  shown  that  by  simple  re-inoculation  chan- 
croid speedily  loses  its  contagious  and  destructive  prop- 
erties), or  that  from  circumstances  connected  with 
venereal  contact,  new  chancroids  are  originated.  It  is 
not  necessary  that  we  should  be  able  to  explain  the 
exact  combinations  which  increase  the  virulence  of  a 
declining  chancroid,  or  which  give  rise  to  it  de  novo,  in 
order  to  prove  that  certain  possible  conditions  really  do 
intensify  and  even  originate  chancroidal  action  or  virus. 
If  there  is  a  difference  between  the  behavior  of  the 
chancroidal  virus,  when  inoculated  by  means  of  a  lancet, 
and  when  inoculated  through  venereal  contact,  that 
difference  can  only  be  referred  to  the  circumstances 
attendant  upon  the  venereal  act.  How  then  do  the 
circumstances  differ  in  an  artificial  and  in  a  venereal  in- 


*  Bumstead  on  Venereal  Diseases,  3d  ed,  page  217  et  seq. 
•j-  Van  Buren  and  Keyes,  p.  470. 


SYPHILIS  AND   THE   GENITO-URTNARY  DISEASES.   2ig 

oculation?  In  the  first  we  have  the  virus  inserted  free 
from  local  or  general  circulatory  exxitement.  In  the 
second  both  are  distinctly  present.  Under  circumstances 
of  equal  cleanliness  and  equally  free  from  undue  ten- 
dency to  purulence,  the  result  might  not  be  markedly 
different.  But  to  the  latter  mode  of  inoculation,  viz., 
that  by  venereal  contact,  we  may  have  in  addition,  vari- 
ous potent  influences,  as  such  increased  irritation  from 
irritant  leucorrhoeal  menstrual  and  preputial  secretions, 
filth,  excessive  venereal  indulgence.  Each  one  of  these 
added  conditions  is  well  known  to  be  capable  of  initiat- 
ing local  inflammation,  and  of  increasing  inflammatory 
processes  already  instituted.  It  can  even  be  shown  that 
a  combination  of  these  conditions  may  originate  a  lesion 
w^hich  distinctly  exhibits  loss  of  tissue,  and  the  secretion 
of  which  is  capable  of  setting  up  a  similar  lesion  on  an 
opposing  surface,  therefore  possessing  the  contagious 
property.  _  If  this  can  be  proven,  it  seems  to  be  'clear 
that  the  difference  between  a  lesion  thus  produced  and 
the  typical  so-called  specific  chancroid  is  simply  one  of 
degree,  and  it  may  be  logically  claimed  that  circum- 
stances which  have  been  shown  capable  of  setting  up 
such  a  lesion  and  which  are  shown  to  add  to  the  viru- 
lence of  a  declining  t3^pical  chancroid,  may,  under 
favoring  conditions,  produce  an  actively  destructive, 
promptly  contagious  lesion,  that  is  to  say,  a  typical 
chancroid. 

Now  it  is  a  well-recognized  clinical  fact  that  certain 
conditions  predispose  to  purulence.  A  lowered  state 
of  health,  free  from  any  disease,  was  shown  in  Dr. 
Wiggleworth's  case,  not  alone  to  favor  simple  suppura- 
tion, but  to  be  capable  of  producing  pus  of  a  distinctly 
contagious  character.* 

Persons  affected  with  Syphilitic  disease,*  Scrofula, 
Scorbutus,  chronic  Splenitis,  etc.,  are  also  predisposed 
to  purulence  ;  this  can  also  be  said  of  the  subjects  of 
every  species  of  dyscrasia.  Local  conditions  may  also 
increase  the  suppurative  tendency.  Redundant  prepu- 
tial tissues,  producing  undue  heat,  moisture  and  friction, 

*  Lesson  i.     Page  6. 


220  Pl^ACTlCAL  CIJNICAL  LESSONS   ON 

favor  purulence  ;  also,  dependent  position.  Prof.  Bock*s 
experiments  in  inoculations  of  chancroid,  showed  that 
the  higher  upon  the  body  inoculations  were  made,  the 
less  tendency  to  excessive  suppuration  and  also  to  phag- 
edena. 

Again,  it  is  a  well-established  fact  that  changes  occa- 
sionally take  place  in  purulent  secretions,  through  which 
new  qualities  and  powers  are  developed.  Benign  or 
*  laudable '  pus  may  thus  acquire  a  highly  irritant  prop- 
erty, as  shown  in  the  following  case : 

Case  I. — A  gentleman  presented  to  me  some  time 
since  complaining  of  an  inflamed  condition  of  the  glans 
penis  and  prepuce,  which  inflammation,  as  he  said,  fol- 
lowed every  connection  with  his  wife.  On  examination 
the  preputial  tissues  were  found  to  be  redundant  and 
the  mucous  membrane  of  the  glans,  as  well  as  of  its 
preputial  reflection,  was  intensely  congested  and  bathed 
in  a  muco-purulent  secretion ;  this  condition  appearing 
at  once  after  connection,  increased,  the  parts  becoming 
moist  and  painful  and  continuing  more  or  less  so  for 
several  days.  The  wife  was  said  to  be  afflicted  with  a 
profuse  purulent  vaginal  discharge.  It  was  also  stated 
by  the  patient  that  connection  with  his  mistress  was  not 
followed  by  any  such  trouble. 

Again  in  certain  cases,  instead  of  a  diffused  inflam- 
mation, we  may  find  more  strictly  localized  inflammatory 
lesions  from  a  similar  cause,  as  will  be  shown  in  the  fol- 
lowing case : 

Case  II. — Mr.  H.  consulted  me  about  five  years  since 
on  account  of  a  pustular  eruption  on  the  preputial  mu- 
cous membrane  near  its  attachment  at  the  fossa-glandis. 
His  first  trouble  had  appeared  about  six  months  pre- 
viously as  a  single  pustule  in  the  fossa  on  the  right  side. 
This  was  shown  to  a  surgeon,  who  notwithstanding  the 
patient's  assurance  that  he  had  no  connection  except 
with  his  wife,  promptly  pronounced  it  a  chancroid  and 
cauterized  it  with  nitric  acid.  Within  a  day  or  two 
several  small  vesicles  appeared  in  the  vicinity,  when  the 
surgeon  came  to  the  conclusion  that  the  primary  lesion 
w^as  of  the  same  character,  and  that  all  were  herpetic. 
The  vesicles  also  became  pustular  and  healed  under  a 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.   221 

simple  astringent  dressing.  There  was  a  history  of  several 
subsequent  similar  attacks.  In  view  of  these  facts  the  half 
dozen  lesions  presenting  on  his  first  visit  to  me  (pre- 
viously alluded  to),  although  distinctly  ulcerative,  with 
inflamed  border,  and  varying  in  size  from  a  small  split 
pea  to  a  grape-seed,  were  considered  of  herpetic  origin. 
The  correctness  of  this  view  was  confirmed  by  their 
rapid  healing  under  simple  astringent  applications.  A 
mild  tannic  acid  lotion  was  prescribed  as  a  prophylactic  ; 
which,  however,  did  not  prevent  recurrence  of  the 
trouble  within  a  week.  This  yielded  like  the  previous, 
and  a  lead  lotion  was  used  with  the  apparent  effect  of 
preventing  further  trouble  for  nearly  a  month,  when  the 
patient,  went  off  on  a  fishing  excursion.  On  his-  return, 
some  ten  days  after,  he  presented  not  only  pustules  on 
the  site  of  the  previous  ones,  but  several  on  the  glans 
penis  exactly  corresponding  to  the  locality  of  pustules  on  the 
preputial  mucous  membrane  wJien  drawn  forward  on  the 
glans.  In  addition  there  was  a  somewhat  painful  en- 
largement of  the  inguinal  glands  of  the  right  side,  at- 
tributed by  the  patient,  to  taking  cold  after  resting  the 
butt  of  his  bass-rod,  for  several  hours,  in  the  groin  of 
that  side.  The  pustules  healed  somewhat  tardily  under 
repeated  applications  of  nitrate  of  silver,  but  the  glands 
went  on  to  suppuration  and  the  formation  of  deep  sinu- 
ses. All  healed,  however,  in  a  couple  of  months,  when, 
three  days  after  connection  with  his  Avife,  another  crop 
of  pustules  was  discovered. 

It  was  then  suspected  that  the  difficulty  was  the  re- 
sult of  the  connection,  and  upon  a  careful  retrospect, 
the  patient  came  to  the  conclusion  that  several,  if  not  all 
of  his  previous  attacks,  had  followed  similar  connection 
after  about  the  same  inferval. 

On  inquiry,  the  wife  was  found  to  have  been,  for  the 
previous  six  months,  under  treatment  for  an  obstinate 
uterine  catarrh  by  a  distinguished  gynecologist,who  fully 
confirmed  my  opinion,  that  contact  with  the  acrid  leu- 
corrhoeal  discharge,  had  occasioned  the  husband's  trou- 
ble. Iler  final  recovery  and  his  subsequent  immunity 
from  the  so-called  herpetic  trouble  fully  supported  this 


222  PRACTICAL  CLINICAL  LESSONS   ON 

conclusion.  Both  the  gentleman  and  his  wife  were 
wholly  free  from  suspicion  of  any  illicit  contact. 

Another  instance  of  ulcerated  and  contagious  lesions 
from  non-specific  causes,  will  be  recognized  in  the  follow- 
ing case : 

Case  III. — Mr.  S.,  aged  twenty-seven,  had  been  mar- 
ried  about  two  years  when,  after  the  birth  of  a  second 
child,  his  wife  suffered  from  a  leucorrhoea  which  con- 
tinued more  or  less  troublesome  for  several  months.  In 
seeking  my  professional  aid  for  himself,  he  stated  that 
during  this  time  he  was  subject  to  occasional  attacks  of 
herpes  preputialis,  and  that  whenever  any  abrasions  oc- 
curred during  connection,  they  Avere  sure  to  be  followed 
by  points  of  ulceration,  which  only  healed  after  several 
days'  treatment  by  bathing  and  simple  cerate.  On  ex- 
amination, several  sharply  cut  ulcers,  from  one  to  two 
lines  in  diameter,  were  seen  on  the  preputial  reflection 
and  in  the  fossa  gland  is.  There  were  also  two  on  the 
glans  penis,  more  recent  and  smaller,  which  matched 
exactly  upon  similar  lesions  on  the  preputial  reflection, 
when  the  prepuce  was  drawn  forward.  The  current 
attack  was  said  not  to  differ  essentially  from  those  to 
which  he  was  accustomed,  except  in  that  it  was  associ- 
ated with  enlargement  of  glands  in  both  inguinal  regions. 
One  point,  especially  in  the  right  groin,  was  inflamed, 
sensitive  to  touch  and  fluctuating.  This  was  opened, 
and  discharged  a  small  quantity  of  laudable  pus.  The 
ulcerations  healed  under  the  influence  of  cleanhness  and 
simple  appHcations ;  the  patient  necessarily  keeping  at 
his  business  as  book-keeper  in  a  large  wholesale  establish- 
ment ;  but  the  glandular  abscess,  the  only  one  occur- 
ring, lasted  for  a  full  month  before  heahng  was  complete. 
The  patient's  general  health  was  fair.  No  scrofulous  or 
syphilitic  antecedents.  The  only  apparent  cause  pre- 
disposing to  ulcerative  trouble  was  a  very  moist  and 
redundant  prepuce,  which  was  subsequently  removed. 
Since  the  circumcision,  now  four  years,  there  has  been 
no  reported  recurrence  of  the  herpetic  trouble. 

Again  it  would  seem  that  ulcerations  may  occur, 
under  certain  circumstances,  as  a  result  of  contact  with 
vitiated  normal  secretions, as  shown  in  the  following; 


SYPHILIS   AND   THE   GENITO-URINARY  DISEASES.   223 

Case  IV. — A  gentleman  who  had  been  under  my  pro- 
fessional care  for  several  years  previous,  and  had  no 
occasion  to  misrepresent  his  case,  sent  for  me.  He  stated 
that  he  had  a  gonorrhoea  acquired  from  an  iUicit  con- 
nection with  the  wife  of  an  intimate  friend,  thirteen  days 
previous.  On  the  completion  of  the  act,  the  lady  dis- 
covered that  she  was  menstruating,  and  so  remarked, 
with  many  expressions  of  regret.  Some  four  days 
after,  a  little  soreness  was  felt  in  the  urethra,  near  the 
orifice,  and  in  a  day  or  two  more,  a  whitish  discharge 
appeared.  He  consulted  a  medical  friend  at  his  club, 
who  after  hearing  of  the  exposure,  pronounced  the  trou- 
ble gonorrhoeal  and  treated  him  with  capsules  and 
injections.  After  ten  days  of  this,  getting  neither  better 
nor  worse  of  the  discharge,  a  tenderness  and  swelling  of 
a  right  inguinal  gland  occurred.  Through  his  wife's 
solicitation  he  sent  for  me  ;  on  examination  I  found  a 
very  scanty  purulent  discharge  from  the  mea'-.us  urina- 
rius,  on  opening  which,  a  sharp-cut  ulceration  was  seen 
just  within  the  orifice,  and  about  the  size  of  a  grain  of 
rice  ;  there  was  no  urethral  tenderness  beyond  this  point. 
The  gonorrhoeal  remedies  were  discontinued,  and  the  le- 
sion thoroughly  cauterized  with  solid  nitrate  of  silver. 
An  inflamed  gland  in  the  right  inguinal  region,  size  of  a 
walnut,  was  also  present,  no  fluctuation  ;  this  was  painted 
with  iodine.  Suppuration  occurred  after  several  days, 
and  the  abscess  was  freely  opened,  discharging  appar- 
ently healthy  pus.  Auto-inoculation  of  this  pus  failed 
to  produce  any  result.  The  urethral  ulcer  resisted  re- 
peated cauterizations  for  about  a  fortnight,  and  then 
healed.  At  about  this  time  the  wife  began  to  suffer 
from  painful  urination,  and  an  examination  revealed  a 
superncial  ulcer  of  mucous  membrane,  the  size  of  a 
three-cent  piece,  just  below  and  infringing  upon  the 
meatus  urinarius,  secreting  pus  freely.  The  husband 
acknowledged  to  an  attempt  at  connection  on  the  even- 
ing following  the  illicit  intercourse,  but  stated,  that 
with  this  exception,  it  was  the  only  one,  except  with 
the  friend's  wife,  that  he  had  for  a  full  month.  In  ad- 
dition, the  larly  had  a  swollen  and  inflamed  inguinal 
gland  in  the   right  groin.     The  lesipn  at   the  meatus 


224  PRACTICAL  CLINICAL  LESSONS  ON 

urinarius  was  touched  with  pure  carbohc  acid,  pre- 
viously  to  which,  however,  the  purulent  secretion  from 
it  was  inoculated  on  the  thigh  of  the  husband.  The 
results  of  this  inoculation  were  negative.  Notwith- 
standing repeated  apphcations  of  the  carbolic  acid,  the 
ulceration  in  the  wife  progressed  in  depth  and  extent 
during  the  foUov/ing  ten  days,  until  it  invaded  the  ure- 
thral canal  a  full  quarter  of  an  inch  ;  then  an  application 
of  pure  nitric  acid  was  made.  During  this  time,  several 
more  unsuccessful  inoculations  were  made  upon  the 
husband.  Much  urinary  distress  occurred,  and  not- 
withstanding the  application  of  the  nitric  acid,  the  ul- 
ceration progressed  along  the  urethra,  which  in  the 
meantime  was  treated  b}-  suppositories  of  iodoform  and 
cocoa  butter.  The  lady  was  in  delicate  health  but  without 
any  recognized  constitutional  dyscrasia.  Tonics  were  ad- 
ministered, but  the  suffering  increased  and  the  ulceration 
was  advancing  into  the  deeper  part  of  the  urethra.  Dur- 
ing all  this  time,  the  lady  with  whom  the  husband  had  the 
illicit  intercourse  and  her  husband  had  been  calling  al- 
most daily,  on  visits  of  courtesy  and  condolence,  and 
were  both  apparently  free  from  any  trouble.  A  distin- 
guished surgeon,  an  authority  on  genito-urinary  diseases, 
was  then  called  in  consultation.  To  my  great  surprise  he 
stated  it  as  his  opinion  that  the  ulceration  in  the  w^ife's 
case  was  non-specific,  and  only  a  coincidence;  not  at  all 
the  result  of  contamination  from  the  husband,  but  from 
other  and  accidental  causes,  and  advised  continuation 
of  application  of  the  iodoform :  if  this  failed  to  benefit, 
a  change  of  air,  a  sea  voyage.  No  improvement  taking 
place  in  a  week,  the  parties  made  a  sea  voyage  of  but 
five  daj^s,  and,  without  other  treatment,  recovery  practi- 
cally took  place  within  a  fortnight. 


SYPHILIS   AND   THE   GENITO-URINAKY  DISEASES.   225 


LESSON  XXVI. 

DOES  DIAGNOSIS  OF  CHANCROID  REST  UPON  CHARACTER 
OF  LESION  OR  ON  ITS  SOURCE.— ANALYSIS  OF  CASE 
IN   POIN.T. 

Inoculability  not  a  sure  test  as  to  origin  of  lesion.  Clinical  case  In  illus- 
tration of  the  fact  that  the  elements  of  desiructiveness  and  contagious- 
ness do  not  depend  upon  a  specific  virus.  Mode  of  development  of 
chancroid.  Varieties  of  chancroid.  Modifications  from  syphilitic  in- 
fluence. 

In  the  previous  lesson,  the  diagnosis  of  simple  origin, 
of  the  apparent  chancroid,  was  made,  in  the  last  case 
presented. 

It  is,  however,  very  evident  that  if  no  lesion  is  to  be 
accepted  as  a  chancroid,  unless  proved  to  have  arisen 
from  contact  with  a  hneal  *  chancroid,  the  specific  nature 
of  chancroid  may  be  accepted  as  demonstrated.  The 
diagnosis,  then,  in  any  instance,  will  not  rest  upon  the 
character  of  the  lesion,  but  upon  its  source.  Thus  in 
the  case  cited,  according  to  this  ruling  we  have  not  a 
chancroid.  A  suppurating  sore  occurs  in  a  lady  who 
never  before  had  an  ulcerative  lesion  of  any  sort;  it 
makes  its  appearance  on  the  urethral  orifice  a  few  days 
after  contact  with  her  husband,  who  has  a  sore  on  his 
urethral  orifice,  which  appeared  a  few  days  after  a  con- 
tact with  another  woman,  and  was  followed  by  a  sup- 
purating bubo.  It  looks  hke  a  typical  chancroid ;  it 
behaves  like  it,  in  its  destructive  tendency,  in  its  advance 
and  its  retrograde  under  treatment,  and  its  final  cicatri- 
zation after  about  two  months'  duration,  under  improved 
hygienic  conditions,  and  yet  it  is  not  accepted  as  chan- 
croid, and  why  ?  First,  because  it  is  clearly  not  the 
product  of  a  lineal  chancroid.  This  is,  of  course,  suffix 
cient  for  those  who  thoroughly  accept  the  specific  nature 
of  the  disease ;  but  there  are  others,  who  decide  this 
lineal  matter  by  the  inoculability  or  non-inoculability  of 

*  i.e.  Descended  in  unbroken  line  from  the  first  chancroid  as  claimed 
by  thos?  who  assert  its  specific  origin. 


226  PRACTICAL   CLINICAL   LESSONS   ON 

its  secretion.  With  them  the  production  of  true  chan- 
croid, by  inoculation  of  a  given  secretion,  proves  that 
secretion  to  have  come  from  a  chancroid.  Assertions 
to  this  effect,  would  appear  to  be  the  result  of  experi- 
ence among  the  class  most  prone  to  suffer  from  the 
results  of  venereal  dissipation,  where  probabilities  are 
all  in  favor  of  chancroid  having  been  acquired  from 
contact  with  chancroid,  and  among  whom  the  contagious 
element  of  the  chancroid  is  kept  by  various  influences 
up  to  a  high  point  of  activity. 

There  can  be,  however,  no  question  that  chancroid, 
proven  of  direct  lineal  descent  from  a  typical  chancroid, 
may  be  met,  which  is  inoculated  with  difficulty  and 
which  is  but  feebly  destructive ;  that  in  point  of  fact, 
chancroid  descended  from  typical  chancroid  is  seen  of 
every  grade  of  destructive  and  contagious  power.  Ex- 
periments have  proved  that  the  true  chancroidal  virus 
gradually  loses  its  power  by  repeated  inoculation,  and 
also  that  various  conditions  of  health  may  prevent  the 
success  of  inoculations  with  fresh  virus  and  under  cir- 
cumstances otherwise  favorable.  "  Susceptibility  to 
inoculation  is  impaired,  or  ev^en  lost,  temporarily,  dur- 
ing the  occurrence  of  any  febrile  attack  or  great  de- 
pression of  the  vital  powers."  * 

Susceptibility  is  also  increased  by  constitutional  dys- 
crasia,  of  various  kinds :  thus  the  syphilitic  dyscrasia,  it 
is  well  known,  predisposes  to  purulence.  T3^pical  chan- 
croids, destructive  and  inoculable  in  generations,  have 
been  repeatedly  proven  to  result  from  the  inoculation  of 
pus  from  an  irritated  syphiUtic  chancre,  also  from  the 
purulent  secretion  of  secondary  syphilitic  lesions,  and 
also  from  scabies  and  acne.  Baumler,  a  recent  German 
authority,  sa3'S :  "According  to  its  source  and  mode  of 
its  origin,  as  well  as  the  susceptibility  of  the  individual 
affected,  will  the  pus  poison  and  evince  this  (chancroidal) 
property,  in  greater  or  less  degree.  Whence  the  pus  de- 
rives this  property,  in  what  it  consists,  and  why  all  pus  does 
not  possess  it  alike,  are  questions  yet  to  be  solved.''  '\. 

Inoculability,  then,  is  not  a  reliable  test  as  to  the  origin 
of  a  sore. 

*  Bumstead,  p.  317, 

f  Zeimssen,  Vol.  III.,  Am.  Ed.,  pages  94  and  95. 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.    22/ 

Again,  inoculation  of  a  leucorrhoeal  secretion,  especi- 
ally from  a  cervicitis,  or  a  metritis,  has  been  claimed 
capable  in  certain  instances  of  producing  inoculable 
sores.  This  is  further  proven  by  the  following  extract 
from  a  distinguished  authority : 

^  "  In  March,  1840,  a  woman  from  the  neighborhood 
of  Aries,  aged  22,  and  remarkably  beautiful  in  form  and 
appearance,  was  thoroughly  examined,  as  was  supposed, 
by  Prof.  Lallemand,  and  no  symptom  of  venereal  disease 
was  discovered.  This  examination  was  made  at  the  re- 
quest of  an  officer,  who  complained  that  she  had  infected 
him.  Several  similar  complaints  being  subsequently 
made  by  others,  she  was  sent  to  the  police  station,  where 
she  was  again  examined  by  M.  Delmar,  in  the  presence 
of  a  considerable  number  of  students.  The  neck  of  the 
uterus  still  appeared  healthy,  but  on  pressing  it  with  the 
speculum  it  discharged  a  muco-purulent  fluid,  which 
was  inoculated,  in  four  places,  upon  the  patient's  thigh, 
with  the  effect  of  producing  four  well-marked  chancroids^ 

In  this  connection  it  will  be  interesting  to  recall  the 
cases  in  the  previous  lesson,  where  ulcerated  lesions  on 
the  penis  resulted  upon  contact  with  virtuous  women, 
who  suffered  only  with  sub-acute  metritis. 

How  do  these  women  differ  from  the  beautiful  woman 
of  Aries,  as  to  the  character  of  these  uterine  secretions? 
Contact  with  them  produces  sores  proven  to  have  a 
contagious  property.  Must  we  then  say  that  they  are 
subjects  of  chancroid  in  the  interior  of  the  cervix,  or 
uterus.'*  The  woman  of  Aries  communicated  chancroid, 
because  she  had  a  uterine  leucorrhoea,  and  because  she 
was  a  prostitute,  not  because  she  had  a  chancroid.  The 
most  rigorous  and  repeated  examinations  failed  to  find 
any  chancroid  upon  her,  and  yet  she  was  the  source  of 
chancroid  to  otJiers. 

The  man,  whose  urethral  sore  communicated  a  similar 
sore  to  his  wife's  urethra,  had  not  chancroid,  because 
his  sore  was  acquired  from  contact  with  menstrual  fluid 
under  circumstances  of  unusual  excitement,  from  a  lady 
of  supposed  virtue,  and  not  from  a  prostitute. 

The  foregoing  cases  and  remarks  are  chiefly  intended 

*  Bumsiead,  p.  359-     3^-1  Ed. 


228  PRACTICAL  CLINICAL  LESSONS  ON 

as  a  preface  to  the  final  and  important  statement,  viz., 
that  the  elements  of  destructiveness  and  contagiousness 
in  a  venereal  lesion  are  not,  in  my  opinion,  dependent 
upon  a  specific  virus,  but  are  engendered  by  various 
causes  and  conditions,  and  that,  clinically,  we  shall  have 
to  deal  with  venereal  lesions  in  every  degree  of  activity, 
which  activity  will  be  found  to  depend  as  frequently 
upon  the  constitution  and  circumstances  of  the  patient, 
as  upon  the  variety  and  origin  of  the  sore  from  which 
the  chancroid  was  derived.  We  may  then  say  that 
CJiancroid 

1st.  Begins  as  a  destructive  process,  either  upon  a 
pre-existing  lesion,  or  upon  sound  tissue.  It  is  usually 
set  up  by  contact  with  the  purulent  secretion  of  a  simi- 
lar destructive  process,  which  had  a  similar  origin,  or 
which  may  have  been  developed  frofn  a  suppurative  process 
of  a  lower  grade. 

2d.  The  destructive  process  thus  initiated  (either 
upon  sound  tissue  or  upon  a  pre-existing  lesion)  pro- 
ceeds steadily  to  the  formation  of  a  pustule,  or  an  ulcer- 
ated surface,  by  a  more  or  less  rapid  m.olecular  necrosis. 
This  necrosis,  occurring  under  differing  conditions,  and 
in  different  localities,  gives  rise  to  characteristic  forms 
of  the  chancroidal  lesion,  which  may  be  described  as 
follows,  viz. : 

1st.  The  Chancroidal  Abrasio7i ;  2d.  The  PUSTULAR 
Chancroid. 

These  may  be  again  divided  into  the  slowly  destructive 
and  the  actively  destriictive  varieties.  We  may  have  as 
modifications  of  these, 

From  Condition.  From  Locality. 

The  Indurated  Chancroid.  The  Follicular  Chancroid. 

The  Inflammatory     "  The  Papulo  Pustular    ** 

The  Gang^renous        "  The  Ecthymatous         ** 

The  Phagedenic         '*  The  Sub- Preputial 

The  Serpigenous        "  The  Chancroidal  Bubo. 

The  Bubonic  Chancroid. 

The  Urethral 

The  Rectal 
The  Ex-Ulcerous  Chancroid  of  Clerc,  and  the  Ulcus  Elevatum. 

Modifications  of  all  the  foregoing  forms  and  varieties 
by  the  coincident  development  of  implanted  syphilitic  ele- 
iiieuts  on  the  site  of  the  chancroidal  lesion. 


SYPHILIS  AND  THE  GENITO-URINARY  DISEASES.  229 


LESSON  XXVII. 

ORIGIN   OF  THE   CHANCROIDAL  ABRASION. 

Most  frequent  localities  of  chancroidal  abrasion.  Physical  appearances. 
Pustular  chancroid.  Mode  of  origin.  Clinical  case  in  iliustraiion. 
Chancroid  divided  into  two  varieties  according  to  activity  of  destruc- 
tive process.  Cases  in  illustration.  Character  of  chancroid  dependent 
upon  its  source.     Chancroid  modified  by  various  influences  and  causes. 

Abrasions  of  mucous  membrane  are  frequent  as  the 
result  of  violence  during  the  act  of  coition :  the}^  occur 
most  frequently  about  the  fourchette  and  the  vestibule 
of  the  female,  and  about  the  preputial  orifice,  and  the 
frenum,  and  along  the  preputial  reflection  of  mucous 
membrane  in  and  behind  the  fossa  glandis  in  the  male. 

All  injuries  of  this  character,  on  being  brought  into 
contact  with  the  secretion  of  an  active  chancroid,  are 
at  once  inoculated,  and  the  suppurative  action  is  thus 
mitiated  over  the  entire  surface"  of  the  lesion.  It  is  to 
the  abrasion,  thus  comphcated,  that  the  term  chancroidal 
is  applied.  To  the  naked  eye  it  appears  at  first  like  a 
simple  scratch  or  chafe,  but  an  examination  of  its  secre- 
tion shows  abundant  pus  corpuscles,  within  three  or 
four  days,  and  often  within  twenty-four  hours.  By  the 
aid  of  a  good  magnifying  glass  the  advancing  molecular 
necrosis  may  be  seen,  in  the  dentated  edges,  in  the 
minute  sloughing  points  on  the  surface  of  the  lesion, 
and  the  secretion  is  inoculable.  Sooner  or  later,  in  ac- 
cordance with  conditions  which  are  known  to  render 
chancroidal  lesions  more  or  less  active,  the  abrasion 
may  be  merged  into  the  characteristic  chancroid.  Its 
shape,  which  at  first  corresponds  with  that  of  the  sur- 
face inoculated,  now  changes,  through  the  advancing 
ulceration.  The  edges  become  ragged  and  abi"upt,  the 
floor,  excavated  and  covered  with  the  debris  of  dis- 
organized tissue,  gives  rise  to  a  profuse  secretion  of 
pus.  The  time  for  these  changes  in  different  cases  may 
vary  from  a  few  days  to  several  weeks. 


230  PRACTICAL  CLtiSriCAL  LESSONS  ON 


ORIGIN   OF  THE  PUSTULAR  CHANCROID. 

The  pustular  chancroid  arises  either  from  the  erosive 
property  of  the  chancroidal  secretions  which  have  been 
deposited  in  the  folds  of  integument  or  mucous  mem- 
brane, or  from  the  absorption  of  the  secretion  into  the 
follicles  of  mucous  membrane,  which  have  been  bathed 
in  the  secretion  of  chancroid. 

The  time  of  its  appearance  after  contact  varies  from 
three  or  four  days  to  eight  or  ten,  and  in  certain 
authentic  instances  even  longer. 

The  foUicular  starting  point  of  the  disease,  assumed  by 
CuUerier,  Bumstead, Acton  and  others,  has  been  substan- 
tiated by  a  case  which  came  recently  under  my  obser- 
vation.    Mr.  W came  to  me  complaining  of  having 

bruised  his  glans  penis  during  a  connection  four  days 
previous.  On  the  morning  following  the  indulgence  the 
part  felt  very  sore  and  was  swollen  and  inflamed.  These 
conditions  had  been  gradually  increasing  in  intensity, 
until  he  pi-esented  his  case  to  me.  I  found  the  inferior 
portion  of  the  glans  much  tumefied,  from  the  meatus 
back  to  the  fossa  glandis,  and  for  half  an  inch  on  either 
side  of  the  median  line  (the  frenum  had  been  smoothly 
carried  away  by  a  chancroid  ulceration,  for  which  I 
had  treated  him  a  3^ear  previous).  The  injured  part 
was  swollen,  and  presented  a  smooth,  shining  surface 
of  a  deep  red  color.  By  the  most  careful  examination, 
with  the  aid  of  a  magnifying  glass,  I  could  not  discover 
any  point  of  abrasion  or  solution  of  continuity  what- 
ever. I  advised  a  simple  water  dressing,  slinging  up 
the  penis,  so  that  engorgement  from  the  dependent 
position  of  the  organ  might  be  reheved,  and  as  per- 
fect rest  as  possible  obtained.  He  called  on  the  follow- 
ing day,  somewhat  relieved,  but  in  appearance  the  parts 
had  not  improved ;  the  color  was  even  deeper  than 
on  previous  examination.  A  wash  of  lead  and  opium 
was  substituted  for  the  water  dressing,  and  the  patient 
advised  to  keep  the  recumbent  position.  On  the  next 
day,  the  third  from  his  visit  to  me,  and  the  seventh 
from  the  impure  connection,  he  again  presented  him- 


SYPHILIS  AND  THE  GENITO-URINARY  DISEASES.   ^31 

self.  The  tumefaction  was  much  the  same;  the  color 
had  deepened  and  was  now  of  a  violet  tinge,  and  I  dis- 
covered, as  though  under  a  glass,  numerous  pale 
whitish  points  varying  in  size  from  a  pin's  point  to  a 
pin's  head,  occupying  a  space  a  quarter  of  an  inch 
broad  and  one  third  in  length  on  either  side  of  the 
median  line  on  the  inferior  aspect  of  the  glans.  Previ- 
ous treatment  was  continued,  and  I  saw  my  patient 
daily  for  three  days  following,  making  in  all  ten  days 
from  the  connection.  On  the  morning  of  the  tenth  day 
I  discovered  some  half  a  dozen  whitish  pointsyV/i"^  iinder^ 
neath  the  mucous  membrane ;  these  were  then  opened 
into  with  a  fine-pointed  bistoury,  and  discharged  minute 
quantities  of  pus.  Under  the  magnifying  glass,  the  lit^ 
tie  cavities  left  after  the  discharge  of  the  pus  were  char- 
acteristic of  chancroidal  ulceration.  In  brief,  all  the 
points,  some  twenty  or  thirty  in  number,  finally  worked 
their  way  to  the  surface,  occupying  some  three  days 
longer,  and  they  soon  coalesced  from  the  extension  of 
the  ulcerative  process,  resulting  in  a  true  chancroid, 
three  fourths  of  an  inch  in  length,  by  one  third  of  an 
inch  in  breadth,  occupying  the  site  of  the  original  white 
points.  The  first  pustules  were  visible  through  the 
mucous  membrane,  but  evidently  deeper  than  its  thick- 
ness, on  the  seventh  day  after  the  absorption.  The  first 
of  these  came  to  the  surface  on  the  tenth  day,  but  it  was 
not  until  the  thirteenth  that  all  had  reached  the  mucous 
membrane  on  their  outward  march.  Applications  of 
the  strong  nitric  acid  resulted  in  a  complete  recovery 
in  a  few  days.  Occasionally  single,  chancroid  is  accom- 
panied as  a  rule,  or  soon  followed,  by  others,  in  the  im- 
mediate vicinity  or  at  different  points.  Commencing 
usually  as  a  fine  whitish  speck,  scarcely  larger  than  a 
pin's  point,  it  soon  increases  in  size,  and,  unless  occur- 
ring on  an  already  inflamed  surface,  presents  a  dis- 
tinctly inflamed  border.  Its  progress  (more  or  less 
rapid, according  to  circumstances  and  conditions  which 
are  known  to  increase  or  retard  its  activity)  is  by  an 
acute  ulceration,  before  which  the  tissues  give  way  in 
irregular  form,  both  at  the  edge  and  floor  (as  hereto- 
fore described  in  case  of  its  advance  from  a  previously 


232  PRACTICAL  CLINICAL  LESSONS  ON 

abraded  surface),  accompanied  with  more  or  less  local 
inflammation  and  pain.  Its  progress,  like  that  of  the 
chancroidal  abrasion,  is  variable.  In  typical  cases, 
under  circumstances  of  usual  health  and  condition, 
reaching  to  the  size  of  a  five-cent  piece,  and  penetrat- 
ing to  the  depth  of  one  or  two  lines,  in  the  course  of 
three  or  four  weeks,  while,  under  other  circumstances, 
its  depth  and  its  extent  may  be  greatly  increased. 

These  pecuharities  of  the  action  of  the  chancroid  are 
the  same,  whether  beginning  on  an  abraded  surface  or 
as  a  pustule,  and  warrant  the  division  of  chancroid  into 
two"  forms  previously  noted,  viz.,  the  sloivly  destructive 
and  the  actively  destructive. 

To  show  you  that  this  division  is  not  simply  a  tech- 
nical one,  I  will  recall  four  cases  presented  to  you  at 
our  last  two  sessions,  which  illustrate  the  validity  of  the 
distinction. 

Case  I. — Wm.  B.,  waiter,  about  25  years  of  age,  gave 
a  history  of  exposure  through  vicious  sexual  contact, 
eight  weeks  previously.  Four  or  five  da3^s  after,  he 
noticed  several  white  pimples  on  his  prepuce  behind 
thQ  fossa glandis.  He  touched  them  with  "blue  stone" 
from  time  to  time,  and  after  a  week,  others  came  on 
his  glans  penis.  He  then  used  a  wash  and  kept  them 
clean,  but  they  refused  to  heal  until  he  went  to  Charity 
Hospital,  about  a  week  ago,  seven  weeks,  after  their 
appearance.  Here  the  sores  on  the  prepuce  were 
cauterized,  on  several  occasions,  wath  nitric  acid,  also 
three  about  the  size  of  a  pea  on  the  glans.  His  general 
condition  as  he  came  before  us  was  fair,  not  rugged. 
He  presented  several  superficial  cicatrices  on  the  in- 
ternal reflection  of  the  prepuce,  and  a  raw  surface 
about  the  size  of  a  three-cent  piece,  yet  unhealed,  but 
granulating  well.  On  the  glans,  were  three  fresh  cica- 
trices, which,  as  I  was  careful  to  show  you,  matched 
exactly  upon  three  distinct  cicatrices  on  the  prepuce 
when  drawn  forward.  This  case  I  presented  as  chan- 
croid of  the  first  variety ;  demonstrated  as  slowly  de- 
structive and  also  contagious,  as  proven  by  auto-inocu- 
lation. 

Case  II. — A  blacksmith,  aged  45,  was  shown  you  in 


SYPHILIS  AND  THE  GENITO-URINARY  DISEASES.   233 

contrast.  A  large  pallid  man,  evidently  in  low  condi- 
tion. Just  two  months  before,  he  also  had  a  connec- 
tion, and  no  trouble  resulted  for  the  next  ten  days, 
when  his  attention  was  attracted  to  his  penis  by  sore- 
ness. He  then  discovered  three  inflamed  pimples,  one 
on  a  redundant  prepuce  and  two  on  the  body  of  the 
penis.  These  progressed  steadily,  and  thinking  they 
were  simple  boils,  he  neglected  them  until  the  scabs 
came  off  a  few  days  ago,  when  he  found  deep  ulcera- 
tions in  their  place,  each  as  large  as  a  dime.  He  was 
admitted  to  Charity  Hospital,  and  the  sores,  which 
were  recognized  as  typical  chancroids,  were  cauterized 
with  nitric  acid.  When  shown  to  you,  three  days  after, 
they  were  still  of  same  size  before  mentioned,  and  fully 
one  fourth  of  an  inch  deep,  penetrating  fully  and  sharp- 
ly the  swollen  integument.  This  case  was  presented  as 
illustrating  the  actively  destriLctive  variety  of  chancroid. 
With  much  the  same  history  as  the  first,  it  was  yet 
seen  to  be  in  marked  contrast  with  it  in  regard  to  the 
activity  of  the  destructive  process.  There  was  no  his- 
tory of  any  antecedent  syphilis  in  either  case. 

Case  III.  was  of  a  lad  of  twenty.  He  was  in  good 
health,  history  of  an  impure  connection  four  weeks  pre- 
viously. A  pimple  near  the  frenum  appeared  five  or  six 
days  after;  this  he  treated  with  repeated  applications 
of  ''  blue-stone,"  and  it  healed  in  a  couple  of  weeks,  hav- 
ing carried  away  the  frenum.  A  soreness  of  the  right 
groin  then  set  in,  and  culminated  in  an  abscess ;  this  I 
opened  before  you,  discharging  about  an  ounce  of  un- 
healthy looking  pus. 

Both  its  appearance  and  course  were  spoken  of  as 
characteristic  of  the  chancroidal  bubo.  The  locality 
of  the  original  sore  was  pointed  out,  as  one  most  liable 
to  be  followed  by  such  an  accident,  inasmuch  as  the 
lymphatic  vessels,  connecting  this  point  with  the  glands 
of  the  groin,  are  known  to  be  numerous  and  superficial. 
No  other  cause  for  such  a  complication  could  be  elic- 
ited. 

Case  IV.  presented  to  you  last  week  came  to  our 
clinic  the  week  previous,  too  late  in  the  hour  to  be 
available  as  an  example.     The  young  man,  25  years  of 


^34  macTical  clinical  Lessons  on 

age,  gave  a  history  of  impure  connection  the  week 
previous,  and  had  just  discovered  a  httle  sore  just 
within  the  urethral  orifice.  A  httle  feehng  of  hardness 
associated  with  this  sore  and  the  long  interval  since  the 
connection,  gave  rise  to  suspicion  of  syphilis.  In  order 
to  clear  this  up,  two  inoculations  were  made  under  the 
left  nipple  of  the  patient  by  Dr.  Bangs,  our  chief  clini- 
cal assistant,  and  the  patient  was  ordered  to  report  on 
the  following  Saturday,  two  da3^s  after;  this  he  failed 
to  do.  He  was  presented  to  you  one  week  after,  with 
a  sore  that  had  penetrated  fully  one  third  of  an  inch, 
and  had  completely  carried  away  the  right  side  of  the 
meatus,  exposing  the  urethra  for  that  distance.  The  at- 
tempted inoculations,  as  shown  you,  were  wholly  abor- 
tive, although  as  I  saw  them  one  half  hour  after  the 
puncture,  they  were  surrounded  by  a  congested  areola 
half  an  inch  in  diameter. 

This  case  I  presented  as  demonstrating  several  points : 
1st.  The  long  interval  of  apparent  incubation.  2d.  The 
slow  progress  of  the  lesion  up  to  the  week  previous, 
thus  marking  it  as  belonging  to  the  slowly  destructive 
variety  of  chancroid,  if  it  were  chancroid.  3d.  The 
sudden  change  from  the  slow  to  the  actively  destruc- 
tive variety.  4th.  The  failure  of  a  carefully  performed 
inoculation  of  the  secretion  of  the  lesion  upon  the  per- 
son of  the  patient,  thus  going  to  prove  that  a  destruc- 
tive chancroid  may  under  certain  conditions  fail  to  give 
an  afhrmative  proof  by  inoculation,  as  claimed  b}^  Bock 
and  others. 

Now  while  I  do  not  present  these  cases  as  absolutely 
proving  the  points  I  desire  to  illustrate,  as  there  may 
be  various  vahd  objections  urged  against  them,  yet  I 
claim  that  they  form  links  in  a  chain  of  evidence  show- 
ing that  chancroid  is  of  variable  quality  and  force,  and 
also  that  the  quality  and  force  is  determined  not  by  any- 
specific  virus  but  by  circumstances  and  conditions.  It 
Mnll  be  well  for  all  who  study  and  treat  this  disease,  to 
be  cognizant  of  this,  and  to  consider  the  causes  which 
are  known  to  effect  the  degi-ee  of  destructiveness  and 
contagiousness  in  each  case,  instead  of  attaching  too 
great  importance  to   the  dogmatic   and   unsupported 


SYPHILIS  AND  THE   GENltC-UklNAkV  DISEASES.   235 

assertions,  of  those  who  claim  one  continuous  lineal 
descent,  for  all  inoculable  and  destructive  venereal 
sores. 

It  may,  I  think,  be  safely  claimed  that  the  character 
of  a  chancroid  is  greatly  dependent  upon  the  degree  of 
activity  of  its  immediate  predecessor,  and  that  it  may 
itself  be  modified  or  intensified  by  the  following  influ- 
ences : 

ist.  General  condition  of  the  person  so  inoculated, 
especially  in  relation  to  any  diathesis  or  dyscrasia. 

2d.  Locality  of  the  inoculation. 

3d.  Influence  of  alcohoKc  stimuli,  low  and  irregular 
living,  etc. 

4th.  Local  sources  of  irritation,  such  as  standing  at 
work,  walking,  or  horseback  exercise,  indulgence  in 
coitus,  uncleanliness,  etc. 

5th.  Application  of  external  irritants,  administration 
of  internal  medicines,  especially  mercurials. 

For  the  convenience  of  description,  various  names 
have  been  applied  by  authors  to  designate  the  several 
modifications  of  chancroid.  These  have  been  already 
cited,  and  will  be  seen  to  fall  naturally  under  two  heads, 
as  modified  by  condition  and  locality. 


236  PRACTICAL  CLINICAL  LESSONS  ON 


LESSON  XXVIII. 

MODIFIED   BY   CONDITION. 

Chancroid  modified  by  condition.  Characteristics  of  simple  chancroid. 
Induration  produced  by  irritation.  Differentiated  from  syphilitic  in- 
duration by  results  of  treatment.  Inflammatory  chancroid.  Descrip- 
tion of.  Causes  of.  Gangrenous  chancroid.  Causes  of.  Character- 
istics of.  Piiagedenic  chancroid.  Definition  of.  Characteristics  of. 
Cases  in  which  it  usually  occurs.  Serpigenous  chancroid.  Description 
of.     Causes  of. 


FIRST:   THE   INDURATED    CHANCROID. 

The  uncomplicated  chancroid  has  a  soft  base  and 
edge  differing  in  suppleness  but  Httle,  if  at  all  from 
the  surrounding  tissue.  In  this  condition  we  have  a 
valuable  diagnostic  mark  separating  chancroid  from  the 
initial  lesion  of  syphilis,  which,  in  typical  cases,  presents 
a  distinct  induration  of  the  tissue  on  which  the  lesion  is 
located.  Venereal  sores  often  present,  however,  about 
which  a  var3'ing  amount  of  induration  is  present ;  not 
seldom  occurring  at  an  early  period  in  a  chancroidal 
lesion,  before  the  loss  of  substance  is  w^ell  marked,  or 
coming  on  later,  in  a  well-marked  chancroid,  giving  rise 
to  suspicion  of  underlying  syphilitic  action.  It  is  well 
then  to  understand,  that  such  induration  may  result  from 
any  form  of  irritation,  and  may  be  a  purely  inflammatory 
aggregation  of  cell  material.  Chancroids  thus  compli- 
cated are  termed  indurated.  The  test  of  the  nature  of 
the  induration,  in  any  case,  is  b}^  simple  treatment.  If  the 
induration  is  thus  rendered  more  dense  and  sharply  de- 
fined, it  will  prove,  as  a  rule  to  which  there  are  few 
exceptions,  that  it  is  the  result  of  true  cell  growth  caused 
by  the  syphihtic  influence,  and  that  the  lesion  is  either 
the  initial  of  syphilis  complicated  by  accidental  ulcer- 
ation, or  that  it  is  a  true  chancroid  complicated  with 
syphilis. 

If,  on  the  contrary,  the  induration  disappears  w^hollj 
under  the  influence  of  rest  and  local  sedatives,  and  the 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.   237 

sore  heals  without  subsequent  induration,  it  is  of  an  in- 
flammatory ciiaracter,  and  the  lesion  so  complicated  is 
proven  of  purely  local  nature,  and  has  thus  been  but  an 
indurated  chancroid. 

'  SECOND  :   THE   INFLAMMATORY   CHANCROID. 

Instead  of  becoming  indurated  under  various  causes 
of  irritation  as  in  the  previous  variety,  the  tissue  sur- 
rounding and  underlying  the  chancroid  may  become 
more  tender  and  swollen,  assuming  a  puffy  appearance, 
and  the  surface  more  intensely  red  and  extended. 

This  condition  may  supervene  upon  any  stage  of 
chancroid,  whether  slowly  pro^^ressing  or  healing,  and  is 
the  evidence  that  a  more  rapid  destructive  action  has 
been  initiated,  or  is  imminent. 

The  same  condition  may  obtain,  on  the  early  appear- 
ance of  the  chancroid,  as  a  result  of  intensity  in  the 
secretion  inoculated,  or  from  constitutional  taint,  excess, 
sexual  and  alcoholic,  as  well  as  from  local  irritation. 

THIRD  :   THE    GANGRENOUS   CHANCROID. 

This  is  but  the  fruit  of  the  unrelieved  inflammatory 
form,  usually  the  result  of  interference  Avith  the  circula- 
tion of  the  part  by  swelling  and  inflammatory  infiltration 
of  the  tissues,  in  which  case,  sloughing  of  contiguous 
structures  occur  en  masse  ;  especially  is  this  apt  to  take 
place  in  debilitated  and  dissipated  subjects.  When 
occurring  upon  persons  in  good  condition,  it  is  the  re- 
sult of  some  mechanical  constriction,  as  in  case  of  sub- 
preputial  chancroids  complicated  with  phimosis. 

The  occurrence  of  gangrene,  in  such  case,  once  an- 
nounced by  the  foetid  odor,  if  not  arrested  by  treatment, 
will  require  but  a  few  hours  for  the  deep  red  surface  of 
the  inflamed  prepuce  to  turn  black,  and  the  slough  to 
disintegrate  and  separate  from  the  living  tissue,  at  or 
near  the  line  of  constriction.  The  effect  of  the  gangre- 
nous accident,  is  to  destroy  all  contagiousness  in  the 
associated  chancroid,  and  the  parts  heal,  after  the  falling 
of  the  slough,  as  if  no  such  complication  had  been  pres- 
ent. 


238  PRACTICAL   CLINICAL  LESSONS  ON 

FOURTH:  PHAGEDENIC  CHANCROID. 

This  term  is  usually  applied  to  all  chancroids  which 
progress  with  unusual  rapidity.  Hence  it  is  made  to 
include  all  degrees,  from  the  inflamed  chancroid,  to  that 
form  in  which  a  sloughing  of  tissues  takes  place  en  masse. 
Instead  of  a  simple  death  of  tissues  through  arrest  of 
circulation,  it  is  the  result  of  an  added  destructive  ele- 
ment, in  some  respects  similar  to  that  which  causes 
hospital  gangrene.  It  is  characterized,  in  the  milder 
forms,  by  gradual  advance  in  destruction  of  tissues,  in 
spite  of  the  ordinary  treatment,  and  of  circumstances 
favorable  to  recovery ;  still  further  by  the  occurrence 
of  a  putrefactive  change.  This  is  heralded  by  a  mawk- 
ish and,  finally,  by  a  distinctly  gangrenous  odor  and  an 
increasing  rapidity  of  the  destructive  action  in  all  the 
dimensions  of  the  lesion,  involving  any  and  all  tissues 
and  vessels.  Progressing  in  aggravated  cases  with 
great  rapidity  ;  destroying  important  parts  even  within 
a  few  hours.  Accompanied,  whenever  the  loss  of  tissue 
is  at  all  considerable,  by  pain  often  very  great,  and  by 
more  or  less  general  constitutional  disturbance.  This 
grave  complication,  is  confined  almost  wholly  to  sub- 
jects of  intemperate  habits,  who  have  also  been  subjected 
to  low  conditions  in  living,  although  it  may  take  place 
in  persons  who,  while  living  under  favorable  hygienic 
conditions,  are  of  scrofulous  habit;  or  it  may  be  the 
result  of  contamination  from  the  secretion  or  exhalations 
from  similar  processes. 

FIFTH:   THE  SERPIGENOUS  CHANCROID. 

This  a  variety  of  the  phagedenic,  which  is  quite  inde- 
pendent of  any  tendency  to  sloughing  or  gangrenous 
action,  and  is  confined  solely  to  the  integument.  It  is 
recognized,  in  its  early  stage,  by  obstinate  resistance  to 
treatment.  Progressing  very  slowly,  and  superficially, 
heahng  on  one  side  under  treatment,  while  progressing 
on  the  other  ;  healthy-looking  granulations  springing  up 
here  and  there — even  little  islands  of  healthy-looking 
tissue  appearing,  apparently  as  the  result  of  some  effi' 


SYPHILIS  AND   THE   GENITO-URINARY   DISEASES.    239 

cient  application,  and  then  melting  away  under  its  con- 
tinuance. Finally,  in  certain  cases,  creeping  over  large 
tracts  of  integument,  the  groins,  perineum  and  buttocks, 
and  in  forms  which  have  suggested  the  name  of  this 
complication.  The  secretions  of  this  variety  of  sore  are 
thin  and  copious,  but  not  inclined  to  form  incrustations. 
They  have  the  power  of  producing  a  chancroidal  sore 
by  auto  inoculation.  It  does  not  necessarily  produce 
the  serpigenous  variety  when  inoculated  upon  other 
persons.  The  subjects  of  this  accident  are  usually  of 
a  scrofulous  diathesis. 

The    modifications  of  chancroid,  from  locality,  are 
chiefly  important  in  regard  to  treatment. 


240  PRACTICAL  CLINICAL  LESSONS  ON 

LESSON   XXIX. 

DIAGNOSIS  AND   TREATMENT   OF   CHANCROID. 

Difficulties  in  diagnosis.  May  be  confounded  with  herpetic  lesions. 
Treatment  of.  Modified  by  condition.  Reasons  why  insignificant 
lesions  often  require  great  consideration.  Management  in  early  stage. 
Treatment  by  excision,  by  cauterization.  Best  methods  described. 
Character  of  subsequent  treatment.  Various  applications.  Diagnosis 
and  treatment  of  the  indurated  chancroid,  of  the  serpigenous  chancroid, 
of  the  follicular  chancroid,  of  the  papulo  pustular  variety,  of  the  ecthy- 
matous  form.  Diagnosis  and  treatment  of  sub-preputial  chancroids. 
Possible  source  of  error  in  diagnosis. 

When  seen  in  the  earliest  stage — viz.,  the  Chancroidal 
Abrasion — it  is  difficult,  and  often  impossible,  to  decide 
whether  it  is  the  result  of  irritation  through  some  vi- 
cious vaginal  secretion  or  lesion  other  than  chancroid,  or 
not.  Hence  all  lesions,  first  seen  as  abrasions,  should 
be  treated  tentatively,  until  the  characteristic  chan- 
croidal ulceration  surface  is  developed.  A  mild,  astrin- 
gent sedative  lotion,  say  three  grains  of  the  acetate  of 
lead  to  the  ounce  of  rose  water,  may  be  applied  on  a  thin 
film  of  borated  cotton  three  or  four  times  a  day.  If  the 
lesion  is  a  pustule,  and  has  made  its  appearance  a  day  or 
two,  or  three  or  four  after  exposure,  it  may  be  of  her- 
petic origin.  A  single  herpetic  pustule  is  not  very 
common.  A  solitary  pustule,  following  five  or  six  days 
after  a  suspicious  connection,  is  more  apt  to  be  chan- 
croid. Careful  examination  will  sometimes  detect  one 
or  more  Httle  vesicles,  or  their  remains,  in  the  immediate 
vicinity  of  the  pustule.  This  warrants  the  inference 
that  the  pustule  had  its  origin  in  a  vesicle,  and  was  thus 
of  herpetic  nature  and  not  chancroid,  which  always 
begins  as  a  pustule.  We  may  venture,  in  such  case,  to 
expect  that  simple  treatment  will  suffice,  especially  if  to 
this  is  added  rest  and  freedom  from  irritation  of  every 
kind.  Nothing  is  more  essential,  in  the  treatment  of 
any  inflammatory  lesions,  than  rest  and  cleanliness.  This 
is  eminently  true  of  chancroid,  and  all  the  lesions  that 
may  be  mistaken  for  it. 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.    24! 

If  the  suspected  lesion  increases,  in  spite  of  rest,  clean- 
liness and  a  mild  sedative  lotion,  it  is  safe  to  include  it 
at  once  under  the  class  Chancroid.  If  it  is  inclined  to 
be  superficial  and  sluggish,  we  will  designate  it  as  of  the 
slowly  destructive  variety,  and  treat  it  with  a  solution 
of  sulphate  of  iron,  applied  on  a  film  of  cotton  two  or 
three  times  daily.  This,  or  an  application  of  a  mild 
solution  of  carbolic  acid,  is  often  promptly  curative.  If 
there  is  much  redness  or  tenderness,  the  watery  extract 
of  opium  may  be  added,  thus : 

5     Ferri  Sulph.  grs.  X. 
Ext.  Opii  Aq.  grs.  X. 
Aq.  ad.   §i. 

M. 


;^     Acid  Carbolic,  grs.  V. 
Sol.  Morph,  U.S. P.   f  i. 
M. 

The  general  condition  should  also  be  considered.  If 
there  is  reason  to  suppose  the  patient  especially  inclined 
to  suppurative  trouble  from  scrofulous  diathesis,  or 
from  general  debility,  or  personal  idiosyncrasy,  in  addi- 
tion to  any  measures  addressed  to  the  general  health,  it 
may  be  well  to  administer  small  doses  of  the  sulphide 
of  calcium,  -^  gr.  every  two  hours,  either  in  freshly 
made  solution  or  in  parvules.  These  measures,  even  in 
the  very  slight  forms  of  suppurative  lesion  (which  are 
oftentimes  difficult  to  distinguish  whether  of  true  chan- 
croidal origin  or  not),  will  in  some  cases  be  found  worth 
considering  and  adopting.  Many  cases  of  most  insignif- 
icant character,  in  a  surgical  point  of  view,  cause  great 
anxiety  and  mental  suffering,  and  should  be  met,  at  the 
outset,  with  the  greatest  consideration  from  the  surgeon, 
not  only  because  of  conditions  present,  but  because  of 
the  possibilities  that  these  innocent-looking  lesions  may 
hide  the  progress  of  a  syphilitic  inoculation.  If  under 
the  above  mentioned  mild  applications,  the  sore  (or  sores, 
as  there  are  commonly  several)  heals  rapidly  or  slowly, 
and,  finally,  cicatrizes  completely,  it  is  yet  most  important 
to  keep  in  mind  the  fact,  that  sometimes,  just  such  lesions, 
even  weeks  after  an  apparent  cure,  begin  slowly  to  in- 


242  PRACTICAL  CLINICAL   LESSONS  ON 

durate  and  finally  demonstrate  that  a  syphilitic  infection 
has  been  initiated.  It  is  by  no  means  infrequent  that 
such  an  accident  occurs  under  cover  of  a  supposed 
chancroid  or  an  herpetic  eruption  ;  or  an  abrasion  irri- 
tated into  seeming  viciousness,  by  simple  vaginal  secre- 
tions, or  a  want  of  cleanliness  or  care. 

If,  however,  the  lesion  shows  early,  that  it  belongs  to 
the  actively  progressive  variety  of  chancroid  ;  if  it  be- 
comes sensitive,  and  progresses  in  depth  and  extent, 
with  undermined  and  irregular  edge,  and  worm-eaten, 
sloughy  floor  (and  this  may  often  be  seen  under  a  good 
magnifying  glass  a  short  time  after  its  appearance),  ac- 
tive measures  are  often  promptly  curative.  If  the  ulcer 
is  situated  on  the  free  margin  of  the  prepuce,  it  may 
sometimes  be  removed  by  excision — previously  cleans- 
ing the  parts  with  a  lo-grain  solution  of  carbolic  acid — 
and  cutting  through  the  entire  thickness  of  the  prepuce, 
then  stitching  the  edges  together.  Union  by  first  in- 
tention may  thus  be  secured.  Great  care  w411  be  neces- 
sary to  prevent  inoculation  of  the  cut  surfaces,  in  which 
case,  the  chancroid  will  be  greatly  increased.  When  situ- 
ated on  the  reflection  of  the  prepuce,  or  in  the  fossa 
glandis,  or  on  the  glans  penis,  or  in  the  vicinity  of  the 
frenum,  or  in  any  locality  on  the  male  or  female  genitals, 
where  they  may  be  thoroughly  and  easily  exposed,  and 
when  the  inflammatory  action  is  not  great,  the  complete 
destruction  of  the  chancroid — one  or  more — should  be 
effected  at  once.  The  best  and  most  convenient  means 
is  by  application  of  the  strong  nitric  acid.  The  soHd 
nitrate  of  silver  stick  is  often  used  for  this  purpose. 
This  is  not  sufficiently  powerful  to  be  depended  upon. 
The  actual  cautery  is  excellent,  but  formidable,  requiring 
ether,  to  be  well  borne.  The  nitric  acid  may  always  be 
at  hand,  and  is,  when  well  applied,  thoroughly  efficient 
in  the  great  majority  of  cases.  A  convenient  method 
of  application  is  by  means  of  a  film  of  cotton,  wound 
upon  the  point  of  a  sharpened  match  or  a  wooden  tooth- 
pick, using  only  enough  to  hold  a  drop  or  two  of  the 
acid.  It  may  thus  be  carried  to  the  surface  of  the  chan- 
croid without  danger  of  dropping  on  healthy  tissues. 
Apply  freely  and  let  it  soak  in,  until  the  floor  and  edge 


SYPHILIS  AND   THE   GENITO-URINARY   DISEASES.    243 

are  completely  saturated,  repeating  the  application,  if 
necessary,  until  this  is  effected.  A  small  chancroid  re- 
quiring a  minute  or  so,  but  one  the  size  of  a  dime  may 
require  several.  If  favorably  situated,  the  size  of  the 
lesion  does  not  contraindicate  the  attempt  to  destroy  it 
in  this  manner.  When  the  saturation  with  the  acid  is 
complete,  a  bit  of  cotton,  soaked  in  a  solution  of  acetate 
of  lead  and  extract  of  opium — 10  grains  each  to  the 
ounce  of  water — may  be  applied.  If  the  sores  are  mul- 
tiple, or  large,  placing  the  patient  under  the  first  effect 
of  ether,  for  the  application,  is  very  desirable.  The 
resulting  slough,  usually  falls  off  within  from  three  to 
five  days,  and,  if  the  application  has  been  effectual,  a 
healthy  granulating  surface  will  be  left.  This  heals 
readily  under  the  slight  stimulation  of  a  weak  solution 
of  carbolic  acid — 5  grains  to  the  ounce.  Should  the 
ulcerative  action  show  a  disposition  to  return,  a  second 
application  may  be  made.  This  may  even  be  required 
a  third  or  a  fourth  time,  if  great  care  has  not  been  taken 
to  destroy  all  the  tissue  involved  in  the  chancroidal 
process.  If,  instead  of  active  destructive  action,  there 
should  simply  be  a  sluggish  and  unhealthy  condition  of 
the  sore  remaining,  this  will  be  best  treated  by  applica- 
tions of  iodoform  in  powder  or  in  combination  with 
equal  part  of  vaseline  : 

^     Iodoform,    31.  Iodoform,   3  i. 

Vaseline,   3  i.  Balsam  Peru,   3  i. 

Oleum  Rosffi.  X.  M. 

M. 

If  the  secretion  is  very  profuse,  10  grains  of  tannic  acid 
may  be  added.  The  odor  of  iodoform  is  often  an  insu- 
perable objection  to  its  use.  The  addition  of  balsam 
Peru,  or  a  few  drops  of  any  of  the  essential  oils — laven- 
der, bergamot,  neroli — or  ten  grains  of  thymol  to  the 
dram  of  iodoform,  will  sometimes  make  it  endurable. 
But  the  best  deodorizer  for  iodoform  that  I  have  found 
is  the  oil  or  attar  of  roses,  in  the  proportion  of  one  drop 
of  the  oil  to  3  i.  of  iodoform.  Nothing  favors  the  best  re- 
sults of  applications,  and  the  most  rapid  healing,  so  effect- 
ually as  complete  rest  of  body  and  mind. 


244  PRACTICAL  CLINICAL  LESSONS   ON 

DIAGNOSIS  AND   TREATMENT  OF  THE   INDURATED  CHAN- 
CROID. 

One  of  the  chief  diagnostic  points  in  chancroidal 
sores,  is  the  freedom  from  positive  induration  ;  a  supple- 
ness of  the  tissues  on  which  they  are  situated.  A  certain 
degree  of  induration,  however,  may  be  present  from 
irritant  or  even  astringent  application,  or  friction  by  the 
clothes  of  the  patient,  raising  the  question  as  to  whether 
or  not  this  is  the  result  of  syphilitic  infection.  In  such 
cases  the  sore  should  first  be  treated  by  removal  of  all 
irritating  surroundings,  by  rest,  and  an  application  of  the 
lead  and  opium  dressing.  If  the  induration  is  not  sj^phi- 
litic,  it  will  pass  off  under  this  treatment,  when  the 
destructive  method  may  be  pursued  as  previously  indi- 
cated. 

The  neglect  of  cleanliness,  undue  exercise,  long  stand- 
ing position  or  irritant  applications,  irregular  hours,  or 
alcoholic  excess,  especially  in  persons  of  dissipated 
habits  and  low  genernl  condition,  often  causes  a  highly 
inflammatory  condition  of  the  chancroid.  The  imme- 
diate result  of  this,  is  to  increase  pain  and  swelling  of 
the  tissues  in  the  vicinity  of  the  chancroid,  and  to  ac- 
celerate the  destructive  action.  Soaking  the  parts  with 
opiated  water  as  hot  as  can  be  borne,  and  as  continuously, 
with  attention  to  the  general  care  of  the  patient,  is  the 
most  prompt  way  of  reducing  this  complication.  If  the 
lesions  are  upon  a  female,  prolonged  hot  sitz  baths  are 
essential. 

DIAGNOSIS   AND   TREATMENT  OF  THE  PHAGEDENIC 
CHANCROID. 

If  relief  does  not  follow,  the  phagedenic  condition 
may  be  superimposed  upon  the  inflammatory.  Still 
more  rapid,  destructive  action  with  putrescent  odor, 
the  true  '*  molecular  gangrene  "  takes  place  as  alluded 
to  in  the  previous  description  of  this  form  of  chancroid. 
When  rapid  destructive  action  is  thus  set  up,  and  impor- 
tant parts  are  threatened,  a  prompt  and  thorough  soakage 
of  the  shreddy,  pultacious,  sloughy  surface  with  strong 
nitric  acid,  is  indicated,  or,  better  still,  ^n  application  of 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.   24$ 

the  actual  cautery,  repeated  from  time  to  time,  until,  by 
application  of  hot  water,  or  by  the  aid  of  charcoal 
poultices,  the  slough  is  removed.  Free  use  of  the  iodo- 
form in  powder  is  also  efficacious,  not  only  for  its  disin- 
fectant but  for  its  ansesthetic  effect.  The  pain  in  rapidly 
destructive  lesions  of  this  sort  is  often  very  great,  anci 
the  internal  administration  of  opium  acts  beneftcently. 
Twenty-grain  doses  of  the  potassio-tartrate  of  iron,  as 
recommended  by  Ricord,  may  usually  be  administered 
to  advantage.  At  Charity  Hospital,  the  treatment  by 
immersion  in  hot  water  by  means  of  the  sitz  bath,  with 
the  water  kept  up  to  100  F.,  has  proved  one  of  the  most 
effective  adjuvants  in  the  treatment  of  sloughing  phage- 
dena in  females,  (in  whom  applications  are  usually  most 
difficult,)  keeping  the  patient  in  for  even  ten  or  fifteen 
hours  consecutively,  and  practically  the  same  method 
for  males. 

DIAGNOSIS   AND   TREATMENT   OF  THE   SERPIGENOUS 
CHANCROID. 

This  is  notably  the  most  rebellious  to  remedies  of  all 
the  forms  of  venereal  lesion.  The  size  to  which  it  insidi- 
ously attains  under  the  usual  treatment  for  superficial 
slowly  destructive  chancroids,  (iodoform,  carbolic  acid, 
etc.,)  is  apt  to  cause  a  hesitation  in  resorting  to  applica- 
tions of  nitric  acid,  acid  nitrate  of  mercury,  or  any  of 
the  destructive  agents  in  ordinary  use  for  the  treatment 
of  chancroids.  The  apparently  healthy  granulations 
which  spring  up  in  the  sore,  and  which  often  go  on  to 
production  of  new  integument  at  one  side,  even  while  it 
is  slowly  melting  away  at  the  other,  flatters  the  surgeon 
into  the  belief  that  mild  measures,  with  appropriate 
constitutional  treatment,  will  finally  effect  a  healing. 
The  result  is,  that  serpigenous  chancroids  are  occasion- 
ally met  which  have  existed  for  years,  and  have  come 
gradually  to  occupy  many  inches  of  surface. 

Especially  is  this  seen  in  females,  where  the  groins, 
the  perineum,  the  entire  vulva,  the  vaginal  walls,  the 
rectum,  and  the  integument  around  the  anus,  maybe  con- 
tinuously involved.  Few  venereal  hospitals,  or  out-door 


246  PRACTICAL   CLINICAL  LESSONS   ON 

departments,  are  without  specimens  of  this  sort.  Passing 
usually  under  the  title  oi  chronic  chancroid,  (to  which  asus- 
picion  of  obscure  syphilitic  constitutional  vice  is  usually 
attached)  they  finally,  in  most  cases,  cease  to  receive 
any  especial  surgical  care,  and  are  often  relegated  to 
the  class  of  incurables.  The  actual  cautery  is  the  one 
and  only  effectual  remedy  in  the  treatment  of  serpig- 
enous  chancroid,  no  matter  what  the  size  or  locality. 
Placing  the  patient  under  the  influence  of  an  anassthetic, 
thoroughly  apply  at  a  white  heat  the  cautery  iron,  or 
the  platinum  point  of  the  gas,  or  the  galvanic  cautery, 
over  the  entire  surface,  following  down  into  every  crypt 
and  sulcus,  with  the  same  animus  as  if  dealing  with  a 
well-marked  case  of  hipns  excedens.  Follow  up  with  hot 
water  immersions,  sedative  lotions,  iodoform,  etc.,  until 
the  slough  has  separated,  and  as  long  as  the  new  sur- 
face appears  in  satisfactory  condition.  If  a  retrograde 
is  threatened,  re-apply  the  cautery,  as  often  and  as  long 
as  is  necessary.  This  will  not  usually  be  required  oftener 
than  once  in  one  or  two  weeks.  Several  cases  within 
my  experience,  that  had  been  considered  beyond  the 
reach  of  surgical  aid,  were,  in  this  way,  finally  brought  to 
a  complete  cure. 

The  modifications  of  chancroid  from  location  are 
noteworthy :  first,  in  regard  to  diagnosis ;  second,  in 
regard  to  treatment. 

DIAGNOSIS  AND   TREATMENT   OF  THE   FOLLICULAR 
CHANCROID. 

This  commencing  apparently  underneath  the  mucous 
membrane,  ma}^  quite  readily  escape  observation,  es- 
pecially when  it  commences  deep  in  the  substance  of 
the  follicle.  The  inflammatory  swelling  and  redness 
often  precedes  the  appearance  of  the  pustule  several 
da3^s. 

DIAGNOSIS  AND   TREATMENT   OF  THE  PAPULO-PUSTULAR 
CHANCROID. 

This  is  most  often  seen  on  the  integument  of  the  labia 
majora,  and  the  mons  veneris,  of  females.  They  are  usually 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.   247 

sluggish  in  character  and  quite  inclined  to  burrow. 
They  originate  in  a  follicle,  and  are  occasionally  quite 
numerous,  a  dozen  or  more  appearing  at  about  the 
same  time,  and  usually  in  connection  with  previously 
existing  chancroids  of  considerable  size,  within  or  about 
the  vulva.  No  applications  have  any  effect  which  are 
not  preceded  by  removal  of  the  small  scab  and  discharge 
of  the  contents  of  the  pustule.  After  this,  the  treatment 
may  be  by  prompt  destructive  agents,  or  by  iodoform. 
If  they  are  not  discovered  and  treated  early  and  effect^ 
ually,  the  probabilities  are  in  favor  of  coalition  of  the 
pustules,  extension  of  the  chancroidal  process,  and  a 
stubborn  persistence  of  the  trouble* 

DIAGNOSIS   AND   TREATMENT   OF  THE   ECTHYMATOUS 
FORM   OF   CHANCROID. 

This  is  covered  by  a  broad  thin  brownish  scab,  is  usu- 
ally on  the  integument  of  the  penis  or  on  the  tliigh,  and 
may  be  mistaken  for  a  simple  herpetic  lesion.  Removal 
of  the  scab  shows  the  characteristic  chancroidal  appear- 
ance of  the  edge  and  floor  of  the  sore.  Very  often  it 
belongs  to  the  slowly  destructive  variety  of  chancroid, 
penetrating  the  thickness  of  the  integument,  or  nearly 
so,  but  without  much  tenderness  or  surrounding  inflam- 
mation. 

Treatment  by  prompt  destruction  of  the  diseased 
tissue,  if  active.  If  sluggish,  application  of  iodoform, 
pure,  or  in  combination  with  tannin,  or  balsam  Peru,  or 
by  carbolic  acid  and  glycerine,  equal  parts,  applied  in 
the  same  way  as  directed  for  use  of  strong  nitric  acid. 
For  the  same  purpose,  a  solution  of  permanganate  of 
potass,  2  grs.  to  the  ounce  of  water,  or  sulphate  of  cop- 
per, 2  to  5  grs.,  may  be  applied  on  a  little  borated  cotton 
or  lint.  This  if  on  the  penis  should  be  protected  by  a 
thin  wrapping  of  oiled  silk,  retained  by  a  narrow  cotton 
bandage,  the  end  of  which  may  be  conveniently  split 
into  four  tails,  brought  around,  and  tied. 

DIAGNOSIS   AND    TREATMENT  OF  SUB-PREPUTIAL    CHAN- 
CROIDS. 

These  require  especial  instructions  for  management, 


248  PRACTICAL  CLINICAL  LESSONS   ON 

only  when,  on  account  of  the  narrowness  or  swelling  of 
the  preputial  orifice,  they  cannot  be  readily  exposed. 
If  the  phimosis  is  congenital,  the  existence  of  sub-prepu- 
tial  chancroids  may  be  infered  by  more  or  less  swelling 
and  tenderness  following  a  suspicious  sexual  connection. 
The  two  difficulties  with  which  they  may  be  confounded 
are,  balanitis  and  initial  lesion  of  syphilis.  Mild  astrin- 
gent sub-preputial  injections,  as,  5  gr.  solution  carbolic 
acid,  10  gr.  solution  of  sulphate  of  iron,  or  the  lead  and 
opium  solution,  may  be  used.  If  the  phimosis  is  inflam- 
matory, persistent  soakage  of  water  as  hot  as  may  be 
comfortably  borne  will  also  be  required.  If  the  reduc- 
tion of  swelling  finally  permits  exposure  of  the  affected 
parts,  they  may  be  treated  according  to  conditions  pre- 
senting. If,  on  the  contrary,  the  swelling  and  sensitive- 
ness increase,  and  blood  is  mixed  with  the  secretion — 
and  this  in  spite  of  rest  and  fomentation — no  time  should 
be  lost  in  slitting  up  the  prepuce  on  the  dorsum,  pre- 
viously syringing  out  the  preputial  cavity  with  a  10 
grain  solution  of  carbolic  acid.  The  division  may  be 
done  with  the  bistoury,  and  the  cut  surfaces  thoroughly 
dried  and  cauterized  with  pure  carbolic  or  nitric  acid. 
But  the  best  way  of  dividing  the  preputial  tissue  in  such 
case  is  by  introducing  a  bit  of  pure  platinum  wire,  per- 
forating the  prepuce  at  the  base  of  the  glans  superiorly, 
and  attaching  it  to  the  galvanic  cautery  battery  and  draw- 
ing it  slowly  through  the  intervening  tissues.  A  small 
wooden  tube,  wetted,  may  be  slipped  over  the  wire  to  pro- 
tect the  glans.  Should  the  lesion  be  situated  on  the  inner 
surface  of  the  prepuce,  or  should  the  slitting  not  expose 
the  whole  diseased  surface,  the  circumcision  may  be 
completed  with  the  wire,  or  with  a  bistoury  if  pre- 
ferred.* Should  the  lesion  pioveto  be  chancroid,  the 
danger  of  inoculation  of  cut  surfaces  is  always  great, 

*  A  case  of  threatened  sloughing  of  the  prepuce  from  chancroidal  action 
in  its  interior,  occurred  in  my  service  at  Charity  Hospital  not  long  since. 
The  swelling  was  enormous,  and  extensive  destruction  of  tissue  was  im- 
minent. The  whole  prepuce  was  removed  by  means  of  the  galvano- 
cautery  wire,  without  haemorrhage.  Several  chancroids  in  the  fossae 
glandis  were  cauterized  at  the  same  time.  The  case  went  on  to  a  rapid 
and  complete  recovery  under  antiseptic  and  simple  applications. 


SYPHILIS  AND  THE  GENITO-URINARY  DISEASES.   249 

no  matter  what  are  the  precautions  taken  ;  but  the  dan- 
ger of  damage  to  the  glans  penis,  through  the  chan- 
croidal action,  if  not  arrested,  by  relieving  tension  and 
by  potent  local  application,  is  so  great  that  the  inocula- 
tion of  the  entire  cut  surfaces  is  a  lesser  evil.  The 
after-treatment  of  the  circumcision,  under  such  circum- 
stances, is  the  same  as  ordinarily  pursued,  until  some 
evidence  of  chancroidal  action  is  manifest.  In  this  and 
in  the  chancroids  or  other  lesions  which  may  be  left  on 
the  glans  or  elsewhere,  the  same  application  already 
described  for  the  lesions  on  open  surfaces,  will  be  re- 
quired. It  must  not  be  forgotten  that  an  initial  lesion 
of  syphilis,  irritated  by  confined  secretions,  may  simu- 
late a  chancroid  in  the  inoculability  of  its  secretion,  and 
that  a  chancroid  may  be  irritated  so  that  induration 
shall  be  present,  simulating  that  of  the  initial  lesion  of 
syphilis.  Previous  instructions  as  to  diagnosis  in  such 
doubtful  cases  will  guide. 


2S0  I>RACT1CAL  CLINICAL  LESSONS  ON 


LESSON  XXX. 

DIAGNOSIS  AND   TREATMENT  OF  CHANCROIDAL  BUBO 
AND   BUBONIC   CHANCROID. 

Manner  in  which  these  lesions  occur.  Definition.  Usual  teachings  in 
regard  to  the  chancroidal  or  virulent  bubo.  All  buboes,  not  syphilitic, 
which  do  not  suppurate,  claimed  as  sympathetic  or  scrofulous.  Phage- 
denic buboes.  All  sores  which  give  rise  to  suppurating  buboes  not 
necessarily  chancroidal.  Early  treatment  of  gland  swelling  associated 
with  chancroid.  Calcium  sulphide  an  efficient  agent  in  arresting  the 
suppurative  process.  Statistics  in  proof  of  this.  Later  treatment. 
Rest  in  bed  important.  Danger  of  extension  of  trouble  through  for- 
mation of  sinuses.  Signs  of  such  accident.  Treatment  necessary  to 
their  arrest  and  subsequent  cure.  Chancroids  of  the  anus  and  rectum. 
Usual  m.ode  of  advent.  Aids  to  diagnosis.  Modes  of  treatment. 
Chancroids  of  anus  and  rectum.  Mode  of  origin.  Aids  to  diagnosis. 
Modifications  of  treatment  to  meet  varied  conditions.  General  reme- 
dial measures  when  local  remedies  prove  inefficient.  The  exulcerous 
form  of  chancroid  the  mildest  type.  Mode  of  treatment.  The  ulcus 
elevatum  not  a  true  chancroid.  Mode  of  treatment.  Modifications  re- 
sulting from  the  union  of  the  contagia  of  chancre  and  chancroid.  Syph- 
ilitic disease  more  likely  to  be  associated  with  the  milder  forms  of 
chancroid.  Frequency  of  this  accident.  The  term  mixed  chancre  a 
misnomer.  No  mixing  possible.  Each  disease  always  independent  of 
the  other,  and  always  of  necessity  antagonistic.  Possible  development 
of  the  initial  lesion  of  syphilis  after  the  healing  of  a  chancroid. 

Inflammation  of  lymphatic  glands  in  connection  with 
chancroid  is  not  uncommon.  The  tumors,  thus  occur- 
ring, are  termed  chancroidal  buboes.  The  inflammation 
is  set  up  in  such  glands  through  the  passage  of  the  pus 
of  the  chanchroid  through  a  l3^mphatic  vessel.  Inflam- 
mation is  immmediately  set  up  in  the  substance  of  the 
gland,  which  soon  swells  and  becomes  painful.  Swel- 
ling of  a  lymphatic  gland,  from  any  cause,  is  usually 
called  a  bubo.  Painful  swelling  of  a  Ij^mphatic  gland 
with  inflammation,  finally  extending  to  the  integument 
covering  it,  is  termed  an  inflammatory  bubo.  When  the 
inflammation  is  set  up  by  inoculation,  through  the  lym- 
phatic vessels  in  connection  with  chancroid,  it  is  termed 
a  chancroidal  or  virulent  bubo. 

When  an  inoculation  is  thus  effected,  suppurative  ac- 
tion is  set  up  which  (it  has  been  taught  as  a  rule  to 


SYPHILIS  AND  THE  GENITO-tJRlNARY  DISEASES.    2^t 

which  there  is  no  exception)  goes  on  to  the  formation 
of  an  abscess,  and  steadily  progressing,  in  the  course 
of  two  or  three  weeks,  sometimes  longer,  finally  finds 
its  way  through  the  parenchyma  of  the  gland  and  the 
overlying  integument.  When  this  is  effected,  the  lesion 
is  called  an  open  chancroidal  bubo,  or  a  bubonic  chan- 
croid. The  purulent  product  of  this  lesion  is,  if  not 
identical,  analogous,  in  character,  to  that  of  the  original 
chancroid. 

This  accident  may  be  initiated  at  any  period  in  the 
course  of  the  chancroid,  from  its  first  appearance  as  a 
small  suppurative  point,  throughout  its  existence.  This 
is  a  strong  argument  in  favor  of  the  early  and  thor- 
ough destruction  of  chancroid.  The  activity  of  the 
suppurative  process  in  the  gland,  bears  a  tolerably  defi- 
nite relation  to  that  of  the  lesion  from  which  it  origi- 
nates. When  the  source  of  the  pus  is  active,  virulent, 
it  is  not  probable  that  any  course  of  treatment,  local  or 
general,  will  prevent  its  termination  in  open  bubo  or 
chancroid.  Where  glands,  associated  with  chancroid, 
inflame  and  yet  do  not  go  on  to  formation  of  abscess, 
or  when  abscess  is  thus  formed  and  its  contents  are  ab- 
sorbed through  treatment,  local  or  general,  it  may  be 
claimed  that  the  chancroid,  from  which  it  is  derived, 
is  of  mild  type.  It  is,  however,  the  habit  of  surgeons  to 
classify  all  buboes  (not  syphilitic)  which  do  not  sup- 
purate, as  sympathetic  or  scrofulous. 

Those  resulting  from  irritation  and  not  from  inocula- 
tion, are  termed  sympathetic  buboes.  Whenever, 
through  suppurative  process,  or  by  surgical  intefer- 
ence,  the  chancroidal  bubo  is  open,  it  goes  on  to  ex- 
hibit the  diagnostic  appearances  of  the  original  chan- 
croid. Pus  secreted  by  it,  when  inoculated  at  other 
points,  or  on  another  individual,  produces  the  charac- 
teristic chancroid. 

When  the  lesion  from  which  it  is  derived,  assumes 
the  phagedenic  form,  the  danger  of  extension  of  phage- 
denic action,  to  the  bubonic  chancroid,  is  imminent. 
Phagedenic  action  may  also  be  set  up  in  a  bubonic 
chancroid  after  the  original  chancroid  has  healed.  In 
such  case  the  treatment  should  be  the  same  as  that  pre- 


^52  PRACTICAL  CLINICAL  LESSONS   ON 

viously  directed  (p.  244)  for  the  phagedenic  chanc- 
roid. 

The  earlier  the  destruction  of  a  chancroid  is  effected, 
the  less  the  danger  of  a  complication  through  medium 
of  the  connecting  lymphatic  vessels.  This  accident  sel- 
dom affects  more  than  a  single  gland,  and  that  usually 
in  the  groin,  corresponding  to  the  side  on  which  the 
chancroid  is  situated.  Occasionally,  however,  through 
intercommunication  of  lymph  canals,  it  may  appear  in 
the  opposite  groin,  even  in  both  groins.  A  sore  of 
very  mild  type  may  give  rise  to  a  bubo  which  may  go 
on  to  suppuration.  AH  sores  which  give  rise  to  abscess 
of  lymph  glands  are  not  necessarily  of  chancroidal  ori- 
gin. It  is  only  by  the  activity  of  the  contagium  and  of 
the  inflammatory  and  destructive  processes,  exhibited 
in  the  inguinal  lesion,  that  we  can  decide  in  what  grade 
to  place  it. 

It  is  safe,  at  first,  to  treat  all  imflammatory  gland 
swellings  in  connection  with  chancroid,  as  if  the}^  were 
of  simple  origin,  that  is,  by  rest  in  the  recumbent  posi- 
tion, by  local  sedative  apphcations,  and  at  once  to  begin 
the  use  of  the  sulphide  of  calcium  internally,  giving  par- 
vules-jL-  gr.  every  hour  or  two,  or  using  a  solution  made 
fresh  every  day — 

■^  Calx  Sulphurata grs.  2. 

M.  Aq 3iv. 

A  teaspoonful  every  hour  or  two.  Also  using  pressure 
(when  it  is  well  borne),  by  means  of  a  compressed 
sponge,  retained  by  a  spica  bandage,  and  moistened 
with  the  lotio  pluinbi  et  opii.  If  pressure  is  productive 
of  pain,  and  this  continues  after  it  has  been  on  for  a  lit- 
tle time,  cold  applications,  even  the  ice  bag,  will  usu- 
ally give  comfort,  and,  later,  allow  the  pressure.  If  the 
feelings  of  the  patient  permit,  the  cold  may  be  main- 
tained and  in  some  cases  abort  the  bubo.  Tincture  of 
iodine  painted  on  morning  and  night  is  also  valuable, 
if  the  patient  cannot  take  the  rest  required  for  other 
treatment.  It  has  the  advantage  of  being  easily  kept 
in  place,  and  the  popular  credit  of  favoring  abortion 
where  this  is  possible,  and  when  this  cannot  be  hoped 


SYPHILIS   AND   THE   GENITO-URINARY   DISEASES.   253 

for,  of  favoring  suppuration.  The  early  evacuation  of 
the  resulting-  abscess  is  usually  advised.  My  habit, 
formerly,  was  to  introduce  a  bistoury  and  make  a  free 
incision  parallel  to  the  long  axis  of  the  tumor  at  the 
earliest  recognition  of  positive  fluctuation.  My  later 
experience  with  the  sulphide  of  calcium,  administered 
internally,  has  caused  me  to  delay  operative  interfer- 
ence until  inefficiency  of  the  sulphide  of  calcium  has 
been  fairly  demonstrated.* 

Once  the  bubo  has  been  laid  open  by  an  incision,  ex- 
tending through  its  long  diameter,  it  will  be  usually 
sufficient  to  pack  the  cavity  with  cotton  or  lint  saturated 
with  the  ordinary  tincture  of  iodine.  This  is  a  good 
styptic  and  has  sufficient  cauterant  property  to  destroy 

*  If  suppuration,  going  on  to  the  production  of  an  open  lesion,  is  in- 
evitable, undoubtedly  it  is  wise  to  encourage  it,  to  evacuate  the  virulent 
product  at  the  earliest  moment,  and  thus  afferd  access  for  efficient  treat- 
ment for  the  destruction  of  this  new  formed  chancroid.  For  this  reason 
I  had  been  an  earnest  advocate  for  early  incision  into  suppurating  bu- 
boes associated  with  chancroid.  My  experience  in  the  few  cases  a'.ove 
alluded  to,  however,  made  me  incline  to  the  belief  that  a  thorough  and 
extended  trial  of  the  sulphide  of  calcium,  in  cases  of  inflammatory  buboes 
associated  with  chancroid,  might  give  such  results  as  to  make  its  use 
imperative  in  every  such  case. 

In  order  to  gain  further  light  on  this  important  matter,  a  systematic 
use  of  the  calcium  sulphide  was  made,  in  my  service  at  Charity  Hospi- 
tal, in  eighteen  consecutive  cases  of  inflammatory  bubo  occuring  with, 
or  as  the  immediate  sequel  of,  well-pronounced  chancroid.  All  the  facts, 
considered  of  importance,  were  noted  by  myself  and  under  my  direction 
by  Dr.  Johnson,  my  House  Surgeon. 

Out  of  eighteen  cases  of  inflammatory  bubo  presenting  the  rational 
evidences  of  chancroidal  origin,  and  treated  systematically  by  the  use  of 
small  doses  of  the  sulphide  of  calcium,  resolution  occurred  in  fifteen, 
and  in  only  three  cases  was  incision  ultimately  required.  Applications 
of  tincture  of  iodine  and  systematic  compression  were  also  employed 
in  every  case. 

If  we  apply  to  these  cases  the  usual  rule  that  chancroidal  buboes  al- 
ways eventuate  in  chanchroidal  abscesses,  always  suppurate  and  require 
evacuation  by  natural  means  or  surgical  procedure,  then  we  must  hold 
that  only  three  out  of  fifteen  cases  of  inflammatory  buboes  associated 
with  chancroid  were  the  result  of  transference  of  the  suppurative  process 
from  the  chancroid  to  the  adjacent  lymphatic  gland.  It  is  just  possible, 
however,  that  the  influence  of  the  sulphide  of  calcium  may,  in  arresting 
suppuration,  extend  to  the  true  ciiancroidal  bubo.  The  apparent  suc- 
cessful use  of  this  drug  in  the  series  of  cases  herewith  presented,  at  least 
.suggests,  and  invites,  a  trial  of  its  efficacy  in  all  instances  of  threatened 
glandular  suppuration,  whether  of  purely  sympathetic  origin  or  asso- 
ciated with  chancroid. 


254  PRACTICAL  CLINICAL  LESSONS  ON 

the  chancroidal  contagium  and  stimulate  the  abscess 
cavity  to  heahhy  granulation.  Iodoform  maj  be  sub- 
stituted if  the  iodine  is  objected  to  on  account  of  pain ; 
the  pain  caused  by  it,  however,  is  very  commonly  tran- 
sitory. Rest  in  bed  is  essential  after  the  opening  of  the 
bubo,  and  until  healing  is  well  advanced,  on  account  of 
the  tendency  to  burrow,  which  abscesses  in  the  region 
of  the  groin  are  wont  to  exhibit.  The  announcement 
of  such  an  accident,  is  often,  through  a  sharp  rise  of 
pulse  and  temperature,  while  the  pain  in  the  vicinity  of 
the  burrowing  may  be  very  slight.  Whenever  fever 
suddenly  starts  up  in  a  patient  suffering  from  an  ingui- 
nal abscess  or  sinus,  even  when  nearly  healed,  it  is  an 
almost  certain  sign  of  the  formation  or  extension  of  a 
sinus,  usually  at  the  most  dependent  portion.  In  this 
event,  after  ascertaining  its  full  extent  by  probing,  in 
exGry  case  slip  in  a  grooved  director  to  the  very  bot- 
tom of  the  sinus,  and  if  its  direction  is  such  as  to  make 
it  surgically  a  proper  thing  to  do,  pass  in  a  blunt  curved 
bistoury  and  cut  out — being  careful  not  to  leave  a  lit- 
tle pocket  at  the  bottom.  Injection  of  tincture  of  iodine 
may  be  made  to  advantage  when  cutting  is  not  con- 
sidered feasible.  For  the  same  purpose,  a  silver  probe, 
dipped  in  nitric  acid,  (which  forms  a  coating  of  ni- 
trate of  silver),  may  be  conveniently  applied  by  inser- 
tion of  the  probe.  When  possible,  in  cases  where  it  is 
not  considered  judicious  to  lay  it  open  throghout,  the 
sinus  should  be  drained  b}^  a  counter  opening,  and,  if 
suppuration  is  extensive,  drainage  effected  by  small 
perforated,  rubber  tubes,  or  carbolated  threads.  If  not 
treated  with  promptness,  extensive  sinuses  may  form, 
requiring  months  to  heal. 

DIAGNOSIS   AND   TREATMENT  OF  THE   URETHRAL*  CHAN- 
CROID. 

A  slight  smarting  on  urination,  or  purulent  discharge, 
appearing  at  the  urethral  orihce,  six  or  eight  days  after 
impure  connection,  is  suggestive  chancroid  of  the  mea- 
tus.    Especially  is  a  little  blood  in  the  discharge  valu- 
able as  a  diag;nostic  point — careful  examination  should 


SYPHILIS   AND   THE    GENITO-URINARY   DISEASES.    255 

be  made  at  once.  This  form  is  quite  common,  and  is 
usually  slow  in  its  progress.  If  the  tissues  at  the  lower 
part  of  the  contracted  orifice  are  very  thin,  as  is  often 
the  case,  snipping-  them  with  a  pair  of  blunt  scissors 
will  sometimes  permit  free  application  to  the  lesion 
without  greatly  increasing  the  surface  thus  exposed  to 
inoculation.  The  use  of  a  meatoscope,  or  a  Toynbees 
ear  speculum,  will  be  of  service  in  making  examination 
and  application  beyond  the  orifice  where,  fortunately, 
chancroids  are  seldom  met.  If  seen  early,  and  the 
meatus  is  of  sufficient  size  to  expose  it  wholly,  after 
cleansing  with  a  weak  carbolic  lotion,  and  the  part 
made  properly  dry,  it  should  be  thoroughly  destroyed 
with  nitric  acid  (after  the  manner  described  for  small 
chancroids  in  other  localities),  subsequently  dressing 
with  a  little  thin  linen  wetted  with  a  sedative  lotion,  or  by 
small  suppositories  composed  of  equal  parts  of  iodoform 
and  cocoa  butter.  If  the  entire  surface  of  the  lesion 
cannot  be  exposed,  treatment  by  iodoform  suppositories 
will  be  best,  using  frequent  hot  water  soakage,  and  in- 
sisting upon  absolute  rest. 

DIAGNOSIS    AND   TREATMENT   OF  CHANCROIDS   OF   THE 
ANUS   AND    RECTUM. 

These  may  occur  as  a  result  of  connection  a  posteri- 
ori, or  from  inoculation.  This  accident,  through  chan- 
croids previously  existing  in  the  vicinity,  is  suggested 
by  pain  in  defecation  and  purulent  discharge.  The  in- 
troduction of  the  finger  may  be  sufficient  to  make  out 
a  diagnosis,  but  the  short  rectal  bivalve  speculum,  with 
narrow  blades,  will  give  access,  when  required,  for 
diagnosis  and  treatment.  But  Httle  especial  treatment 
will  be  required,  beyond  that  already  suggested  for 
other  varieties.  Cauterization  to  be  made  use  of  when 
called  for;  and  absolute  cleanliness  insisted  on. 

If  great  difficulty  and  pain  are  experienced  in  intro- 
duction of  necessary  instruments  and  dressings,  or  if 
the  lesion  is  penetrating  the  tissues  rapidly,  or  is  rebel- 
lious to  treatment,  the  external  sphincter  may  be  divided 
through  the  lesion^  and  the  cut  surface  treated,  together 


256  PRACTICAL   CLINICAL  LESSONS   ON 

with  the  chancroid,  by  application  of  iodoform  and  tan- 
nin suppositories,  subsequently  using  nitric  acid  if  nec- 
essary to  arrest  the  disintegrating  process,  and  then 
resuming  the  iodoform  suppositories,  until  healing  is 
complete.  The  use  of  the  vaginal  speculum,  in  treat- 
ing chancroid  of  the  ostium  vaginas  and  parts  beyond, 
is  absolutely  essential,  not  alone  for  the  security  of 
reaching  the  full  extent  of  the  lesions,  but  for  occasional 
examinations  beyond  the  site  of  existing  lesions,  and 
to  insure  against  insidious  development  of  new  points. 
The  healthy  tissues  adjacent  to  contagious  surfaces, 
should  be  kept  constantly  separate  by  thin  layers  of 
carbolated  or  iodoform  dressing ;  and  by  occasional 
soakage  in  hot  water,  secure  absolute  cleanliness,  and 
relief  to  inflammatory  conditions. 

In  all  cases  of  chancroid,  which,  when  judiciously 
cared  for,  are  still  rebellious  to  treatment — particularly 
those  where  ulcerations  and  sinuses  have  occurred,  the 
general  condition  of  the  patient  should  receive  especial 
attention.  In  cases  of  scrofulous  habit,  cod  liver  oil, 
iron,  etc.,  are  often  of  service  in  hastening  the  healing  of 
a  sluggish  chancroid.  The  case  cited  page  223,  where 
all  measures  failed,  until  a  change  of  cHmate  and  a  sea 
voyage  wrought  a  prompt  cure,  is  significant. 

The  Exulcerous  Form  of  Chancroid,  described 
as  existing  without  perceptible  loss  of  tissue,  being 
either  on  a  level  or  slightly  above  the  surrounding  sur- 
face, and  hence  not  characterized  by  the  usual  marks  of 
chancroidal  action — must  be  classed  as  of  the  mildest 
form,  and  amenable  usually  to  local  astringent  sedative 
applications.  The  sulphate  of  iron  as  a  lotion — 10  grs. 
to  §  I  of  water — is  often  promptly  curative. 

The  Ulcus  Elevatum,  a  lesion  of  the  same  type,  is 
scarcely  to  be  classed  among  chancroids,  as  it  lacks 
wholly  the  characteristic  features  of  such  lesions.  It  is 
usually  not  larger  than  a  flattened  pea,  and  found  on 
the  borders  of  a  prepuce,  which  is  bathed  in  secretions 
more  or  less  vitiated.  It  partakes  more  of  the  nature 
of  a  papilliary  hypertrophy,  and  a  local  treatment  adapt- 
ed to  such  overgrowth  should  be  employed,  viz. :  re- 
moving first  the  source  of  the  irritant  secretion,  then 


SYPHILIS  AND   THE   GENITO-URlNARY  DISEASES.   25f 

apply  the  powdered  persulphate  of  iron,  or  if  necessary, 
to  touch,  lightly,  with  pure  chromic  acid. 

MODIFICATIONS  RESULTING  FROM  DEVELOPMENT  OF 
SYPHILITIC  ELEMENTS,  IMPLANTED  ON  THE  SITE  OF 
A   CHANCROIDAL   LESION. 

The  milder  the  form  of  chancroid,  the  more  likely  to 
develop  a  syphilitic  complication,  after  syphilitic  ex- 
posure. Active  chancroidal  action,  is  doubtless  as  de- 
structive of  the  syphilitic  contagium,  as  of  healthy  tis- 
sue, but  when,  as  is  sometimes  the  case,  the  contagia  of 
both  chancre  and  chancroid  are  implanted  on  the  same 
abrasion,  at  about  the  same  time,  the  chances  are,  that 
the  syphilitic  disease  germ,  will  find  its  way  into  a 
lymph  space,  and  out  of  the  reach  of  harm,  before  con- 
tact with  the  destructive  chancroidal  cell.  This  latter, 
going  steadily  on  in  its  characteristic  destructive  action, 
while  the  prohferation  of  the  syphilitic  disease  germs  is 
progressing  underneath.  So  it  often  happens,  that, 
while  the  chancroid  is  in  full  typical  action,  the  tissues 
underlying  and  surrounding,  become  gradually  stiffened 
and  indurated,  until  a  sore  presents,  equally  character- 
istic of  both  chancroid  and  the  initial  lesion  of  syphilis. 
This  is  known  as  the  "■  mixed  chancre!' 

It  will  be  at  once  seen  that  there  is  not,  and  never 
can  be,  any  mixing  of  the  contagion  of  chancroid  and 
syphihs,  one  representing  the  destruction  and  the  other 
the  growth  of  tissue  elements.  Necessity  for  the  treat- 
ment of  the  chancroid,  is  the  same  as  before,  but  the 
complication  requires  the  constitutional  treatment  ap- 
propriate for  syphilis,  at  the  first  moment,  when, 
through  development  of  other  characteristic  syphiHtic 
lesions,  the  diagnosis  can  be  definitely  settled.  The 
development  of  induration  of  syphilis,  after  the  healing 
of  a  chancroid  (the  tissues  about  which  have  remained 
supple  throughout  its  existence)  is  also  not  uncommon, 
The  possibihty  of  such  an  occurrence  must  be  borne 
prommently  in  mind,  for  several  weeks  after  the  heal- 
ing of  any  lesion  resulting  from  a  suspicious  sexual 
contact. 


258  PRACTICAL  CLINICAL  LESSONSi 


Remedies  and  Remedial  Agents  Referred  to  in  this  Volume,  Aki) 
THEIR  Application. 

For  Local  Application  to  the  Initial  Lesion  of  Syphilis. 

in  the  non-ulcerative  forms;  the  indurated  papule,  and  the  dry  scaling 
patch. 

No.  I.  White  precipitate  ointment,  vaseline;  equal  parts;  or, 

No,  2.  The  mild  mercural  ointment;  or, 

No.  3.  The  oleate  of  mercury,  6  per  cent  solution,  with  vaseline; 
equal  parts. 

Apply  by  gently  rubbing  in  a  small  quantity  morning  and  night. 

In  all  Uncomplicated  Open  Initial  Lesions. 

No.  4.  Calomel  pure,  dusted  on  and  protected  by  a  thin  film  of  bof- 
ated  cotton;  or  soaking  the  cotton  with  the  following  solution,  and 
apply;  or, 

No.  5,  Calomel,  20grs. ;  lime  water,  4  ounces;  mix;  or, 

No.  6.  Corrosive  sublimate,  logrs. ;  lime  water,  6  ounces;  mix. 

For  the  Inflamed  Initial  Lesion. 

Diluted  solution  of  sub-acetate  of  lead,  4  ounces. 
No.  7.  Aqueous  ext,  opium,  10  grs. ;  or, 

No.  8.  Iodoform,  30  grs.;  glycerine,  i  ounce;  oil  of  roses,  I  drop; 
mix;  apply  on  lint. 

For  the  Phagedenic  or  Gangrenous  Form. 

No.  9.  Iodoform,  a  sufficient  quantity;  i  drop  of  the  oil  of  roses  to  30 
grs.;  applied  freely. 

Internal  Remedies  for  Treatment  of  Syphilis,  from  date  of 
Initiation,  for  at  least  12  Months. 

No.  10.  Blue  mass.,  60  grs.;  exsicated  sulphate  of  iron,  30  grs. ;  make 
30  pills  (pil.  duplex),  one  three  times  a  day;  or. 

No.  II.  Protoiodide  of  mercury,  exsicated  sulphate  of  iron,  40  grs.; 
aqueous  extract  of  opium,  4  grs.;  mix,  make  40  pills;  one  three  times  a 
day. 

External  Applications  for  Innunction. 

No.  12.  The  mild  mercurial  ointment;  a  piece  as  large  as  a  filbert 
rubbed  in  thoroughly,  morning  and  night;  or, 

No.  13.  Oleate  of  mercury,  10  per  cent  solution;  vaseline  an  equal 
quantity;  a  teaspoonful  rubbed  in,  morning  and  night,  always  in  a  fresh 
and  protected  place. 

For  Mercurial  Fumigation,  or  the  Mercurial  Bath. 

No.  14.  Calomel,  (resublimed)  15  to  30  grs.;  nightly,  or  every  two  or 
three  nights,  until  its  specific  effect  is  obtained.  Further  directions  on 
page. 


SYPHILIS   AND   THE   GENITO-URINARY  DISEASES.   259 

After  the  Twelfth  Month,  the  Mixture  of  the  Biniodide 
OF  Mercury  and  the  Iodide  of  Potassium. 

No.  15,  Biniodide  of  mercury,  3  grs. ;  iodide  of  potassium,  120  grs. ; 
tincture  of  orange  peel,  l-^  ounces;  syrup  of  orange  peel,  i^  ounces; 
distilled  water,  up  to  8  ounces;  mix;  a  teaspoonful  three  times  a  day,  or 
if  gastric  or  intestinal  irritation  ensues — 

No.  16.  Biniodide  of  mercury,  3  grs.;  iodide  of  potassium,  120  grs  ; 
fluid  extract  of  thuja,  8  ounces;  mix;  a  teaspoonful  three  times  a  day. 

In  addition  to  the  foregoing, 

During  the  Sequels  of  Syphilis. 

No.  17.  Iodide  of  potassium,  i  ounce;  distilled  water,  6  drams;  mix. 
Beginning  with  5  drops  in  a  small  glass  of  water,  or  preferably  of  milk, 
increasing  by  a  drop  for  each  dose,  gradually  increasing  the  diluent  to  a 
tumblerful,  until  sixty  drops  are  taken,  equivalent  to  60  grains  of  the 
iodide  of  potassium,  three  times  daily,  after  meals,  unless  iodism  occurs. 
In  this  case  begin  again  with  the  minimum  dose,  and  increase  as  before 
up  to  40  drops,  and  then  increase  by  i  drop,  until  60  grains  is  again 
reached.  If  decided  benefit  does  not  take  place,  the  quantity  may  be 
even  farther  increased  up  to  twice  that  amount,  in  grave  cases,  and  con- 
tinued, if  well  borne,  until  all  signs  of  the  disease  have  disappeared. 

If  the  iodide  of  potassium  is  not  tolerated,  the  following  may  be 
administered. 

No.  18.  Iodine,  24  grains;  distilled  water,  2  ounces;  iodine  of  potas- 
sium, 48  grains;  dissolve  and  add  common  molasses,  or  Stuart's  syrup, 
8  ounces;  let  it  stand  12  hours.  Administer  from  a  dessertspoonful, 
gradually  increased  to  a  tablespoonful,  thrice  daily  after  meals. 

In  the  Alopecia  of  Syphilis. 

The  following  lotions  will  be  found  serviceable: 

No.  ig  Bi-chloride  of  mercury,  3  grains;  hydrochloric  acid,  30  min- 
ims; distilled  water,  8  ounces;  then  add,  spirits  of  cologne,  i  ounce; 
rose  water,  i  ounce;  glycerine,  -|- ounce;  mix;  or 

No.  20.  Castor  oil,  i^  ounces;  rectified  spirit,  i|  ounces;  spirits  of 
cologne,  I  ounce;  tincture  of  cantharides,  2  drams;  mix,  apply  nightly, 
washing  the  hair  every  morning  with  castile  soap. 

For  Local  Applications  in  the  Treatment  of  Chancroid  in  the 
Slowly  Destructive  Forms. 

No.  21.  Sulphate  of  iron,    10  grains;   aqueous  extract  of  opium,    10 

grains;  aistilled  water  to  i  ounce. 

No.  22.   Carbolic  acid,  5  to  10  grains;  solution  of  morphia,  (U.  S.   P., 

containing  i  grain  of  morphia),  i  ounce.     If  the  secretion  is  profuse, 
No.  23.   Iodoform  and  tannic  acid,  equal  parts,  dusted  on;  mix;  in  the 

more  acute  forms, 

No.  24.  Iodoform,  60  grains;  vaseline.  60 grains;  oil  of  roses,  idrop;  or, 
No.  25.  Iodoform,  60  grains;  oil  of  roses,  i  drop;  apply  in  powder;  or, 
No.  26.   Iodoform,  i  dram;  carbolic  acid,  i  minim;  oil  of  peppermint, 

6  minims;  mix. 


26o  PRACTICAL  CLINICAL  LESSONS. 

For  Destruction  of  the  Chancroid,  or  PhactEdenic  CoNDiTioNS. 

Nitric  acid,  pure;  galvano  cautery,  or  the  thermo  cautery. 

For  Sluggish  Conditions. 

No.  27.  Permanganate  of  potassa,  2  grains;  distilled  water,  I  ounce. 
No.  28.  Carbolic  acid,  pure;  applied  daily;  or, 

No.  29.  Carbolic  acid,  10  grains;  glycerine,  2  drams;  distilled  water, 
6  drams;  mix;  apply  on  a  thin  film  of  cotton. 

For  Application  to  Bubonic  Ulcers,  and  Sinuses. 

No.  30.  Tincture  of  iodine,  pure;  and,  for  arrest  of  suppuration  in  any 
case. 

No.  31.  Sulphate  of  calcium,  i  grain;  distilled  water,  2  ounces;  a  tea 
spoonful  every  hour,  solution  to  be  freshly  made  every  day;  or, 

Parvules,  ^  grs.  each. 

For  Applications  to  the  Phagedenic  Chancroid. 

No.  32.  Hot  water  immersion,  temperature  100°  F. ;  actual  cautery; 
charcoal  poultices 

Internally,  (Ricords  formula). 

No.  33.  Poiassio  tartrate  of  iron,  ^  ounce;  distilled  water,  3  ounces; 
syrup,  3  ounces;  mix;  a  dessertspoonful  to  a  tablespoonful  three  every 
six  hours,  preferably  after  meals. 


COLUMBIA  UNIVERSITY  LIBRARY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

C28(239)M10O 

RC201 

Obis 
Practical  clinical  lessons  on 
syphilis. 


0t4 
v.l 


